THE  W   T   KEENER  CO 

MCOICAL    BOOKStlXlKS. 


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n 


DISEASES  OF  THE  EYE. 


BY 


EDWARD  NETTLESHIP,  F.R.C.S., 

OPHTHALMIC  SURGEON  TO  ST.  THOMAS'S  HOSPITAL  ;   SXJRGEOX  TO  THE  ROYAL  LONDON 

(MOORFIELDS)  ophthalmic  HOSPITAL  ;  LATE  OPHTHALMIC  SURGEON  TO 

THE  HOSPITAL  FOR  SICK  CHILDREN,  GREAT  ORMOND  STREET. 


FOURTH  AMERICAN 

FROM  THE 

FIFTH  ENGLISH  EDITION. 
WITH  A  CHAPTER  ON 

EXAMINATION   FOR  COLOR-PERCEPTION. 


BY 
WILLIAM  THOMSON,  M.D., 

PROFBSSOR  or  OPHXnALMOLOGY    IW  THE  JEFFEKSON    MEDICAL    COLLEGE  OF  PHILADELPHIA. 


PHILADELPHIA: 

LEA    BROTHERS    &    CO 

1890. 


\yOLC 


2% 


Entered  according  to  Act  of  Congress,  in  the  year  1890,  by 

LEA   BROTHERS   &   CO., 

in  the  oflSce  of  the  Librarian  of  Congress.    All  rights  reserved. 


DORN  AN,     PRINT  BR. 


TO 


JONATHAN  HUTCHINSON,  F.R.S., 

CONSULTING   SURGEON  TO   THE   MOORFIELDS   OPHTHA.LMIC   HOSPITAL 
AND  TO  THE  LONDON  HOSPITAL,  ETC., 

THIS 

BOOK  IS  DEDICATED 

IN   GRATEFUL   ADMIRATION   OF   HIS   EMINENT   QUALITIES   AS    A 
CLINICAL   TEACHER   AND   INVESTIGATOR. 


AMERICAN  PUBLISHERS'  PREFACE. 


In  presenting  to  the  medical  profession  the  fourth  American 
edition  of  Dr.  Nettleship's  work  on  "  The  Diseases  of  the 
Eye,"  the  publishers  desire  to  state  that  no  pains  have  been 
spared  to  place  it  in  every  particular  upon  a  level  with  the 
latest  developments  of  the  specialty  of  which  it  treats. 

In  addition  to  a  most  thorough  and  careful  revision  by  the 
author,  comprising  many  important  changes  and  additions, 
there  has  been  inserted  as  a  supplement  the  chapter  from 
the  previous  edition  upon  the  Detection  of  Color-blindness, 
from  the  pen  of  Dr.  William  Thomson,  whose  painstaking 
investigations  upon  this  subject  are  widely  known,  and  his 
methods  generally  adopted  for  the  examination  of  railroad 
employes. 

Every  care  has  been  taken  with  the  typography,  and  in 
all  respects  the  publishers  feel  assured  that  the  work  will  be 
found  to  merit  in  an  increased  degree  the  confidence  awarded 
by  the  profession  to  the  previous  editions. 

Philadelphia,  1890. 


PREFACE  TO  THE  FIFTH  EDITION. 


The  general  work  of  revision  and  of  correction  for  the 
press  for  the  present  edition  has  been  carried  out  with  much 
pains  by  Mr.  Holmes  Spicer. 

The  bulk  of  the  volume  has  been  but  little  increased, 
though  I  have  taken  every  care  to  include  such  new  matter 
as  seemed  suitable  for  a  book  of  this  class,  and  considerable 
changes  will  be  found,  especially  in  the  chapter  on  Opera- 
tions. The  number  of  illustrations  is  the  same  as  in  the 
last  edition;  but  Figures  9,  50,  53,  95,  and  131  have  been 
replaced  by  new  cuts ;  and  for  the  colored  papers  of  the 
former  editions,  there  has  been  substituted,  at  the  suggestion 
of  the  Publishers,  a  copy  of  Professor  Holmgren's  well- 
known  plate,  executed  at  Stockholm  with  the  kind  permission 
of  the  Professor. 

September,  1890, 


PREFACE  TO  THE  FIRST  EDITION. 


The  aim  of  this  little  book  is  to  supply  students  with  the 
information  thev  most  need  on  diseases  of  the  eve  durinsr 
their  hospital  course.  It  was  apparent  from  the  beginning 
that  the  task  would  be  a  difficult  one,  all  the  more  as  several 
excellent  manuals,  covering  nearly  the  same  ground,  are 
already  before  the  public.  That  not  one  of  them  singly 
appeared  exactly  to  cover  the  ground  most  important  for  the 
first  beginner  in  clinical  ophthalmology  encouraged  me  to 
attempt  the  present  work. 

The  scope  of  the  work  has  precluded  frequent  reference  to 
authors,  those  named  being  chiefly  such  as  have  made  recent 
additions  to  our  knowledge  in  this  country.  I  am  greatly 
indebted  to  Dr.  Gowers,  Dr.  Barlow,  and  other  friends  for 
much  information,  and  for  many  valuable  suggestions.  My 
best  thanks  are  due  to  Mr.  A.  D.  Davidson  for  his  kind 
assistance  in  reading  the  sheets  for  the  press. 

WiMPOLE  Street  :  October,  1890. 


CONTENTS, 


PART  I._MEAXS  OF  DIAGNOSIS. 

PAGE 

List  of  Abbreviations 25 

CHAPTER  I. 

Optical  Outlines. 

Lenses  and  prisms  ;  Refraction  of  the  eye,  and  conditions  of  clear 
vision  ;  Numeration  of  spectacle  lenses  ;  Table  showing  the 
equivalent  numbers  of  lenses  made  bv  the  inch  scale  and 
metrical  scale  respectively         ......     25-42 

CHAPTER   IL 

External  Examination  of  the  Eye. 

Examination  of  :  (1)  Surface  of  cornea  ;  (2)  Tension  of  eye  ; 
(3)  Field  of  vision  ;  (4)  Color-perception  ;  (5)  Acuteness  of 
sight ;  (6)  Accommodation  ;  (7)  Pupils  :  (8)  Color  of  iris  ; 
(9)  External  bloodvessels  of  eye;  (10)  Mobility  of  eye  and 
field  of  fixation  ;  (11)  Squint  of  strabismus,  apparent  strabis- 
mus, measurement  of  strabismus;  (12)  Diplopia;  (13)  Ap- 
parent size  of  objects  ;  (14)  Protrusion  and  enlargement  of 
eye 43-62 

CHAPTER   III. 
Examination  of  the  Eye  by  Artificial  Light. 

(1)  Focal  or  "oblique'"  illumination. 

(2)  Ophthalmoscopic  examination  ;  Experiments  showing  indi- 
rect and  direct  methods  ;  Use  of  the  ophthalmoscope. 

Indirect  method  ;  Appearance  of  optic  disc  ;  scleral  ring,  physio- 
logical pit,  lamina  cribrosa:  of  choroid:  of  retina:  vessels, 
yellow  3pot,/oi-ea  centralis. 


Xll  CONTENTS. 

PAGE 

Direct  method  :  Examination  of  vitreous  ;  Determination  of  re- 
fraction ;  Table  of  relation  between  refraction  and  length  of 
eye  ;  Examination  of  fine  details  by  direct  method. 

Retinoscopy  (Keratoscopy) (33-S9 


PART  II.— CLINICAL  DIVISION. 

CHAPTER   IV. 

Diseases  of  the  Eyelids. 

Blepharitis  ;  Stye  ;  Meibomian  cyst ;  Horns  and  warty  forma- 
tions ;  MoUuscum  contagiosum ;  Xanthelasma ;  Pediculus 
pubis.  Ulcers  :  Rodent  cancer  ;  Tertiary  syphilis  ;  Lupus  ; 
Chancre.     Congenital  ptosis  ;  Epicauthus        .         .         .     91-98 

CHAPTER  V. 
Diseases  of  the  Lachrymal  Apparatus. 

Epiphora,  stillicidium  lachrymarum,  and  lachrymation. 

Epiphora  from  alterations  of  punctum  and  canaliculus  ;  Dacryo- 
liths. 

Diseases  of  lachrymal  sac  and  nasal  duct ;  Mucocele  and  lachry- 
mal abscess  ;  Stricture  of  nasal  duct ;  Lachrymal  abscess  in 
newborn  infants      ........     99-104 

CHAPTER  VI. 

Diseases  of  the  Coxjunctiva. 

General  diseases  :  Purulent  and  gonorrhoeal  ophthalmia  ;  Muco- 
purulent ophthalmia  ;  Catarrhal,  and  other  forms  of  muco- 
purulent ophthalmia  ;  Membranous  and  diphtheritic  oph- 
thalmia ;  Atropine  and  eserine  irritation  ;  Partial  diseases: 
Granular  ophthalmia,  follicular  conjunctivitis  :  Results  of 
granular  ophthalmia ;  Pannus,  distichiasis,  and  trichiasis, 
organic  entropion  ;  Chronic  conjunctivitis  ;  Amyloid  dis- 
ease ;  Spring  catarrh  ;  Conjunctivitis  from  drugs  ;  Primary 
shrinkage  of  conjunctiva       ......     105-125 


CONTENTS.  Xlll 

CHAPTER  VII. 
Diseases  of  the  Cornea. 

PAGE 

A.  Ulcers  and  non-specific  inflammation. 

Appearances  of  the  cornea  in  disease:  "Steamy"  and 
"ground-glass"  cornea;  Infiltration;  Swelling;  Ulcera- 
tion ;  Nebula  and  leucoma. 

Symptoms  in  ulceration  :  Photophobia  ;  Congestion  ;  Pain. 

Clinical  types  of  ulcer  :  Central  ulcer  of  children  ;  Facet- 
ting ulcer  ;  Phlyctenular  aS'ections  ;  Phlyctenular,  or  recur- 
rent vascular,  ulcer.  Marginal  conjunctivitis.  (Spring 
catarrh)  ;  Creseentic  ulcer  of  old  age  ;  Infective  ulcers  ;  Ab- 
scess and  suppurating  ulcer  ;  Hypopyon  ;  Onyx. 

Treatment  of  ulcers  of  cornea. 

Conical  cornea. 

B.  Diffuse  keratitis. 

Syphilitic  keratitis.  Other  forms  of  keratitis  :  Keratitis 
punctata ;  Corneal  changes  in  glaucoma ;  Buphthalmos 
(Hydrophthalmos)  ;  Calcareous  film  ;  Arcus  senilis  ;  Inflam- 
matory arcus  ;  Opacity  from  use  of  lead  lotion  ;  Staining 
of  conjunctiva  or  cornea  from  use  of  nitrate  of  silver         126-151 

CHAPTER  VIII. 

Diseases  of  the  Iris. 

Iritis,    symptoms  :    Muddiness    and   disccloration    of   iris ;    Syn- 
echiae ;    Corneal   haze  ;    Ciliary   congestion ;    Pain ;    Lymph 
nodules  ;  Hypopyon. 
Results  of  iritis. 

Causes  :  Syphilis  ;  Rheumatism  ;  Gout ;  Sympathetic  dis- 
ease ;  Injuries  and  local  causes  ;  Chronic  iritis. 
Treatment  of  iritis. 
Congenital    irideremia ;    Coloboma ;    Persistent    pupillary   mem- 
brane         152-163 

CHAPTER  IX. 

Diseases  of  the  Ciliary  Region. 

Episcleritis  (or  Scleritis),  Sclero-keratitis,  and  allied  diseases: 
Cyclitis  (Irido-choroiditis,  "Serous  iritis");  Traumatic 
cyclitis  (or  Panophthalmitis). 


XIV  CONTENTS. 

PAGE 

Sympathetic  affections :    Sympathetic    irritation  ;     Sympathetic 

inflammation ;  Treatment 164-177 

CHAPTER  X. 

Injuries  op  the  Eyeball. 

Contusion  and  concussion  injuries:  Rupture  of  eyeball;  Intra- 
ocular hemorrhage  ;  Detachment  of  iris  ;  Dislocation  of  lens  ; 
Detachment  of  retina  ;  Rupture  of  choroid  ;  Paralysis  of 
•iris  and  ciliary  muscle ;  Iritis ;  Commotio  retinse ;  Trau- 
matic myopia. — Treatment  of  blows  on  eye ;  Dislocation  of 
lens  ;  Use  of  ice  after  injuries  of  eyeball. 

Surface  wounds  of  eyeball :  Abrasion  and  foreign  body  on 
cornea;  Foreign  body  on  conjunctiva. 

Burns  and  scalds  ;  Prognosis  uncertain  for  some  days  :  Lime- 
burn  ;  Serious  results  of  severe  burns. 

Penetrating  wounds  of  eyeball :  Slight  cases  ;  Severe  cases  ; 
Traumatic  cataract ;  Cyclitis  ;  Foreign  body  in  eye.  Treat- 
ment. Rules  as  to  the  excision  of  wounded  eyes.  Electro- 
magnet for  removing  bits  of  iron  ....     178-188 

CHAPTER  XI. 

Cataract. 
Senile  changes  in  lens . 

Definition  of  cataract :     General   cataract :     Nuclear  and 
cortical,  each  may  be  hard  (senile)  or  soft  (juvenile)  ;  Con- 
genital.    Partial   cataract :    Lamellar ;    Pyramidal  ;    Ante- 
rior and  posterior  polar.     Cataract  following  wound  or  con- 
cussion of  eyeball. 
Dislocation  of  lens. 
Primary  and  secondary  cataract. 
Symptoms  and  diagnosis  of  cataract.     Prognosis  before  and  after 

operation. 
Treatment:    Palliative;    Atropine.     Radical:    Extraction,    Dis- 
cission or  solution,  Suction. 

Rules  as  to  operating  for  cataract  ;  Artificial  ripening  of 
cataract ;   Causes  of  failure  after  extraction  ;  Hemorrhage  ; 
Suppuration  of  globe  ;  Iritis  ;  Prolapse  of  iris  ;  Influence  of 
lachrymal  disease. 
Sight  after  removal  of  cataract 

Treatment  of  lamellar  cataract  ....     189-209 


CONTENTS.  XV 

CHAPTER  Xir. 

Diseases  of  the  Choroid. 

PAGE 

Participation  by  the  retina  and  the  vitreous. 

Appearances  in  health  ;  Appearances  in  disease.  Atrophy,  pig- 
ment in  choroid  and  retina  ;  Exudations,  syphilitic,  tuber- 
cular ;  Rupture;  **  Colloid"  change  ;  Hemorrhages. 

Clinical  forms  of  disease :  Syphilitic  choroiditis  disseminata ; 
Myopic  changes  ;  Central  senile  choroiditis  ;  Other  forms. 

Coloboma;  Albinism 210-225 

CHAPTER  Xlir. 
Diseases  of  the  Retina. 

Appearances  in  health:  Bloodvessels,  yellow  spot,  and  "halo" 
around  it ;   "  Opaque  nerve-fibres." 

Appearances  in  disease  :  Congestion;  Retinitis,  (1)  Diffuse, 
(2)  and  (3)  Localized,  with  white  spots  and  hemorrhages, 
(4)  Solitary  patch. 

Hemorrhage;  Pigmentation;  Atrophy;  Disc  in  Atrophy  of 
retina ;  Detachment. 

Clinical  forms  of  disease :  Syphilitic  retinitis  ;  Albuminuric  ; 
Hemorrhagic ;  Retinitis  apoplectica  and  large  single  hemor- 
rhages ;  Embolism  and  thrombosis  ;  Retinitis  pigmentosa ; 
Retinitis  from  intense  light  ......     226-247 

CHAPTER  XIV. 

Diseases  of  the  Optic  Nerve. 

Relation  between  changes  at  the  Disc,  disease  of  the  Optic  Nerve, 
and  affection  of  Sight. 

Pathological  changes  in  optic  nerve. 
Appearances    of    optic    disc    in    disease  :     Inflammation,    optic 
neuritis,  papillitis,  or  choked  disc  ;  Atrophy  after  papillitis  ; 
Papillo-retinitis. 

Etiology  of  papillitis.  Retro-ocular  neuritis  ;  Syphilis 
causing  papillitis.     The  pupils  in  neuritis. 

Atrophy  of  disc :  Appearances  and  causes  ;  Clinical 
aspects  ;  State  of  sight,  field  of  vision,  and  color-perception  ; 
A.  Double  atrophy  ;    C.  Single  atrophy         .         .         .     248-263 


XVI  CONTENTS. 

CHAPTER  XV. 

Amblyopia  axd  Functional  Disorders  of  Sight. 

PAGB 

"Amblyopia"  and  "Amaurosis:"  Single  amblyopia:  From 
suppression  or  congenital  defect  ;  from  defective  images ; 
from  retro-ocular  neuritis.  Double  amblyopia  :  Central  am- 
blyopia (Tobacco  amblyopia). 

Hemianopia ;  Hysterical  amblyopia  and  Hypersesthesia  oculi  ; 
Asthenopia. 

Functional  disorders  of  vision  ;  Endemic  nyctalopia ;  Snow  and 
Electric-light  blindness.  Hemeralopia ;  Colored  vision ; 
Micropsia  ;  Muscse  volitantes  ;  Diplopia  ;  Malingering ; 
Color-blindness 264-280 

CHAPTER  XVI. 

Diseases  of  the  Vitreous  Humor. 

Usually  secondary  to  other  diseases  of  eye. 

Examination  for  opacities  :    Cholesterine  ;   Blood  ;  Blood- 
vessels in  vitreous  ;  Cysticercus. 

Conditions  causing  disease  of  vitreous  :  Myopia ;  Blows  and 
wounds  ;  Spontaneous  hemorrhage  ;  Cyclitis,  choroiditis, 
retinitis  ;   Sympathetic  disease      .....     281-285 

CHAPTER  XVII. 

Glaucoma. 
Primary  and  secondary. 

Primary  glaucoma  :  Premonitory  stage  ;  Chronic  or  Simple  ; 
Subacute  ;  Acute  ;  Absolute. 

Ophthalmoscopic  changes  ;  Cupping  of  disc. 
Symptoms  explained  ;  Mechanism. 
General  and  diathetic  causes  ;  Treatment ;  Prognosis. 
Secondary  glaucoma  ;  Conditions  causing  it  .         .         .     286-306 

CHAPTER   XVIII. 

Tumors  and  New-growths. 

A.  Of  the  conjunctiva  and  front  of  the  eyeball.  Cauliflower 
wart  ;  Lupus  ;  Syphilitic  tarsitis  ;  Pinguecula  ;   Pterygium  ; 


CONTENTS.  XVll 

PAGE 

Lymphatic  cysts  ;  Dermoid  tumor  ;  Episcleritis  simulating 
tumor  ;  Fibro-fatty  growth ;  Cystic  tumors  ;  Fibrous  and 
Bony  tumors  ;  Epithelioma  ;  Sarcoma. 
B.  Intra-ocular  tumors.  Glioma  of  retina  ;  Pseudo-glioma. 
Sarcoma  of  choroid  ;  Tubercular  tumor  of  choroid.  Tumors 
of  iris  :  Sarcoma  ;  Sebaceous  tumor  ;  Cysts  ;  Granuloma.    307-316 

CHAPTER  XIX. 
Lnjl'ries,  Diseases,  and  Tumors  of  the  Orbit. 

Contusion  and  concussion  injuries:  Emphysema  of  orbit; 
Traumatic  ptosis. 

Abscess  and  cellulitis  of  orbit  ;  Inflammation  and  abscess  of 
lachrymal  gland. 

Wounds  :   Of  eyelids  ;  of  orbit ;  Large  foreign  bodies  in  orbit. 

Tumors  of  orbit.  General  symptoms  :  Distention  of  frontal 
sinus  ;  Ivory  exostosis  ;  Tumors  growing  from  parts  around 
the  orbit  ;  Pulsating  exophthalmos  ;  Cystic  tumors  ;  Solid 
intra-orbital  tumors.  Naevus.  Dermoid  tumor  in  eye- 
brow          317-325 

CHAPTER    XX. 

Errors  of  Refraction  and  Accommodation. 

Emmetropia  ;  Ametropia. 

Myopia.  Symptoms  :  Insufficiency  of  internal  recti.  Pos- 
terior staphyloma  and  crescent ;  Other  complications.  Tests 
for.  Causes.  Measurement  of  degree.  Treatment ;  Spec- 
tacles ;  Tenotomy. 

Hypermetropia.  Symptoms  :  Accommodative  asthenopia,  Con- 
vergent strabismus.  Tests  for  hypermetropia  ;  Treatment ; 
Spectacles  ;  Treatment  of  the  strabismus. 

Astigmatism.  Regular  and  irregular  ;  Seat  ;  Focal  interval ; 
Cylindrical  lenses  ;  Forms  of  regular  astigmatism  ;  Detec- 
tion and  measurement ;  Spectacles. 

Unequal  refraction  in  the  two  eyes  (Anisometropia). 

Presbyopia  :    Rate  of   progress  ;    Treatment  :    Range   and  region 

of  accommodation  in  E.,  M.,  and  H.      .         .         .         .     326-362 


XVin  CONTENTS. 

CHAPTER   XXI. 

Strabismus  and  Paralysis. 

PAGE 

Definition  of  strabismus  ;  Diplopia  ;  True  and  false  image  ; 
Homonymous  and  crossed  diplopia  ;  Suppression  of  false 
image. 

Causes  :  Strabismus  from  Over-action  ;  from  Weakness ;  from 
Disuse ;  from  Weakness  following  tenotomy  ;  from  Paraly- 
sis. 

Paralysis  of  Sixth  nerve  (external  rectus)  ;  of  Fourth  nerve 
(superior  oblique)  ;  of  Third  nerve  ;  Ophthalmoplegia  ex- 
terna. Primary  and  secondary  strabismus ;  Giddiness  in 
paralytic  strabismus. 

Affections  of  Internal  muscles  of  eye:  Physiology  and  action 
of  drugs  on  the  Internal  Muscles  ;  Affections  of  Pupil 
alone ;  of  Accommodation  alone ;  of  Pupil  and  Accom- 
modation ;  Ophthalmoplegia  interna. 

Causes  of  external  ocular  paralyses  :  Syphilitic  growths  ; 
Meningitis  ;  Tumors  ;  Rheumatism.  Causes  of  internal 
ocular  paralyses.     Treatment. 

Nystagmus 3(53-380 

CHAPTER   XXII. 

Operations. 

A.  On  the  eyelids. 

Epilation  ;  Eversion  of  lid  ;  Meibomian  cyst  ;  Inspection 
of  cornea ;  Spasmodic  entropion  ;  Organic  entropion  and 
trichiasis  ;  Ectropion  ;  Blepharoplasty ;  Ptosis  ;  Cantho- 
plasty  ;  Peritomy  ;  Symblepharon. 

B.  On  the  lachrymal  apparatus. 

Lachrymal  abscess  ;  Slitting  canaliculus  ;  Stricture  of 
nasal  duct,  (1)  Probing,  (2)  Incising,  (3)  Syringing. 

C.  For  strabismus. 

Tenotomy  :  Graefe's  :  Critchett's  ;  Liebreich's.  Re- 
adjustment and  Advancement. 

D.  Excision  of  the  eye  and  alternative  operations. 

Abscission,  Optico-ciliary  Neurotomy,  Evisceration, 
Stretching  Infra-trochlear  nerve. 

E.  On  the  cornea. 

Foreign  body  ;  Paracentesis  ;  Corneal  section  for  ulcer  ; 
Conical  cornea. 


CONTENTS.  Xix 

On  the  ins. 

Iridectomy :  For  artificial  pupil ;  for  glaucoma.  Irido- 
desis  ;  Iridotomj  (iritomyj. 

Sclerotomy. 
For  cataract. 

Extraction:  Linear;  (rraefe's  -'modified  linear;"  Short 
flap ;  Corneal  section  ;  Old  flap.  Complications  during 
extraction.  Treatment  after  extraction.  Secondary  opera- 
tions. Discission  or  Solution  ;  Suction.  Treatment  after 
solution  and  suction. 

Anaesthesia  in  Ophthalmic  Surgery   ....     381-428 


PART  III.— DISEASES  OF  THE  EYE  IX  RELA- 
TION  TO  GENERAL  DISEASES. 

CHAPTER  XXIII. 
A.  General  Diseases. 
Eye  diseases  caused  by  :  Syphilis,  acquired  and  inherited,  diseases 
of  optic  nerve  and  oculo-motor  nerves  in  relation  to  syphilis  ; 
-  Smallpox  ;  Scarlet  fever,  typhus,  etc. ;  Diphtheria  ;  Measles  ; 
Mumps ;     Chicken-pox      and      whooping-cough ;     Malarial 
fevers  ;    Relapsing   fever ;    Epidemic   cerehro-spiual   menin- 
gitis ;  Purpura  and  scurvy  ;  Pyaemia  and  septicaemia  ;  Lead- 
poisoning  ;  Alcohol ;  Tobacco  ;    Bisulphide  of   carbon  ;  Qui- 
nine ;    Kidney   disease :    Diabetes ;    Leucocyth^mia  ;  Perni- 
cious   anaemia  ;  Heart   disease ;    Tuberculosis  ;  Rheumatism 
and  gonorrhoea!  rheumatism  ;  Gout,  personal  and  inherited  ; 
Struma  ;  Entozoa  ••......  447 

B.  Local  Disease  at  a  Distaxce  from  the  Eye. 

Eye  symptoms  caused  by  :  Megrim  ;  >'euralgia  and  sympathetic 
disease  ;  Diseases  of  brain ;  Cerebral  tumor  ;  Syphilitic  dis- 
ease ;  Meningitis  ;  Cerebritis  ;  Hydrocephalus  ;  Diseases  of 
spinal  cord  :  Myelitis  ;  Locomotor  ataxy.  General  paralysis 
of  insane.  L.iteral  and  insular  sclerosis.  Motor  disorders  of 
eyes  and  affections  of  the  pupils  in  cerebral  and  spinal  disease. 
Convulsions  in  relation  to  imperfections  of  teeth  and  lens.  447-454 


XX  CONTKNTS. 

c.  The  Eye  Shaking  i>-  a  Locai,  Disease  of  the 
Neighboring  Parts. 

PAGE 

Eye  symptoms  caused  by  :  Herpes  zoster  of  fifth  nerve  ;  Paralysis 
of  fifth,  of  facial,  and  of  cervical  sympathetic  nerves  ;  Exoph- 
thalmic goitre  ;  Erysipelas  and  orbital  cellulitis  .         .     454-457 

The  teeth  in  inherited  syphilis    .......  457 


[SUPPLEMENT. 

Examination  for  Color-perception. 

Instructions  for  examination  of  railway  employes  as  to  vision, 
color-blindness,  and  hearing  :  Acuteness  of  vision  ;  Range 
of  vision  ;  Field  of  vision  ;  Color-sense  ;  Hearing  ;  Expla- 
nations             461-473] 


APPENDIX. 


Formulae     ...........  475 

Shades.     Protective  glass  ........  487 

Test-types,  etc 488 

Ophthalmoscopes         .........  488 

Perimeters  ..........  490 

Tests  for  color-blindness     ........  490 

Index 493 


PART   I. 

MEANS  OF  DIAGXOSIS. 


The  following  abbreviations  wi 

1  be  used  in  this  work : 

T. 

Tension  of  the  eyeball. 

cm. 

Centimetre. 

E. 

Emmetropia. 

mm. 

Millimetre. 

M. 

M3-opia. 

D. 

Dioptre,   the    unit    in  the 

H. 

H)-perinetropia. 

metrical  system  of  meas- 

m. H. 

Manifest  hypermetropia. 

uring     lenses  ;     a    lens 

1.  H. 

Latent  hypermetropia. 

whose  focal  length  is  1  m. 

Pr. 

Presbyopia. 

y.  s. 

Yellow  spot  of  the  retina. 

As. 

Astigmatism. 

b.  D. 

Optic  disc. 

Ace. 

Accommodation. 

F. 

Field  of  vision. 

P- 

Piinctum      proximum 
near  point. 

or 

V. 

Visus,  acuteness  of  sight, 
power    of    distinguishing 

r. 

Punctum  remotissimum 

or 

form. 

far  point. 

Symboh.   +  A  convex,   —  a   cou- 

p.l. 

Perception  of  light. 

cave,  lens.    'Foot,     Inch, 

P. 

Pupil. 

"Line. 

m. 

Metre. 

CHAPTER    I 


OPTICAL  OUTLINES. 


1.  Rays  of  light  are  deviated  or  refracted  when  they 
pass  from  one  transparent  medium,  e.  g.,  air,  into  another 
of  different  density,  e.  g.,  water  or  glass. 

2.  If  the  deviation  in  passing  from  vacuum  into  air  be 
represented  by  the  number  1,  that  for  crown-glass,  of  which 
ordinarv  lenses    are  made,  i?   1.5,   and  for   ror-k    crvstal, 


26  OPTICAL    OUTLINES. 

"pebble"  of  opticians,  1.66.  Such  a  number  is  the  "re- 
fractive index"  of  the  substance.  Every  ray  is  refracted 
except  the  one  which  falls  perpendicularly  to  the  surface, 
Fig.  1,  a. 

FiG.l. 


Tjmm^^m^^^^^^^^m^^^^Bm*. 


Refraction  by  a  medium  ^vith  parallel  sides. 

3.  In  passing  from  a  less  into  a  more  refracting  medium 
the  deviation  is  always  toward  the  perpendicular  to  the 
refracting  surface ;  in  passing  from  a  more  into  a  less 
refracting  medium  it  is  always,  and  to  the  same  extent, 
away  from  the  perpendicular,  Fig.  1,  h\  i.e.,  the  angle  x  in 
the  figure  =  the  angle  y. 

Fig.  2. 


Refraction  by  a  prism. 

4.  Hence,  if  the  sides  of  the  medium,  Fig.  1,  m,  be  par- 
allel, the  rays  on  emerging  (6')  are  restored  to  their  original 


OPTICAL    OUTLINES.  2Y 

direction  (b)  and,  if  the  medium  be  thin,  very  nearly  to 
their  original  ^ja^/i. 

5.  But  if,  as  in  a  prism,  the  sides  of  m  form  an  angle, 
Fig.  2,  a,  the  angles  of  incidence  and  emergence,  x  and  y, 
still  being  equal,  6'  must  also  form  an  angle  with  b.     The 

Fig.  3. 


Apparent  displacement  of  object  by  a  prism. 

angle  a  is  the  ''refracting  angle"  or  edge  of  the  prism  ; 
the  opposite  side  is  the  "base."  The  figure  shows  that 
light  is  always  deviated  toward  the  base.  The  deviation, 
shown  by  the  angle  d,  is  equal  to  about  half  the  refracting 

Fig.  4. 


Refraction  the  same  for  different  angles  of  incidence. 

angle  a  if  the  prism  be  of  crown-glass.  The  relative  direc- 
tion of  the  rays  is  not  changed  by  a  prism  ;  if  parallel  or 
divergent  before  incidence,  they  are  parallel  or  similarly 
divergent  after  emergence.  Fig.  3. 


28  OPTICAL     OUTLINES. 

6.  An  object  seems  to  lie,  or  is  "projected,"  in  the 
direction  which  the  rays  have  as  they  enter  the  eye;  ob, 
Fig-.  3,  seen  by  an  eye  at  a'  or  6',  seems  to  be  at  o'b,  where 
it  would  be  if  the  rays  a'  b'  had  undergone  no  deviation. 

7.  For  very  thin  prisms  the  deviation,  a  and  j8,  Fig.  4, 
remains  the  same  for  varying  angles  of  incidence.  For 
thin  lenses  this  is  expressed  b}^  saying  that  the  angle 
d,  Fig.  5,  is  the  same  for  the  rays  a  a',  b  b',  and  c  c' ,  inci- 


FiG.  5. 


Refraction  by  a  thin  lens  the  same  for  all  rays  incident  at 
the  same  distance  from  the  axis. 


dent  at  different  angles,  but  at  the  soAne  distance  from,  the 
axis. 

8.  An  ordinary  lens  is  a  segment  of  a  sphere,  plano- 
convex or  plano-concave,  or  of  two  spheres  whose  centres 
are  joined  by  the  axis  of  the  lens,  biconvex  or  biconcave. 

9.  A  lens  is  regarded  as  formed  of  an  infinite  number 
of  minute  prisms,  each  with  a  different  refracting  angle. 
Fig.  G  shows  two  such  elements  of  a  convex  lens,  the  angle 
(a)  of  the  prism  at  the  edge  of  the  lens  being  larger,  and 
therefore,  in  accordance  with  §  5,  refracting  more,  than  j3, 
the  angle  of  the  prism  near  the  axis.  If  tw^o  parallel 
rays,  a  and  6,  traverse  this  system,  a  will  be  more  refracted 
than  b,  and  the  ravs  will  meet  at  f.     Fiu'.  7  shows  the  cor- 


OPTICAL     OUTLINES. 


respouding  facts  for  a  concave  lens,  by  which  parallel  rays 
are  made  divergent. 


Fig.  6. 


Prismatic  elements  of  a  convex  lens. 
Fig.  7. 


Prismatic  elements  of  a  concave  lens. 

10.  The  only  ray  not  refracted  by  a  lens  is  the  one 
passing  thronghthe  centre  of  each  surface;  compare  §2, 
which  is  the  principal  axis,  ax,  Fig.  8.    Secondary  axes  are 

Fig.  8. 


Axes  of  a  lens. 


rays,  such  as  s.  ax,  entering  and  emerging  at  points  on  the 
lens  parallel  to  each  other,  and  hence,  see  §  4,  not  altered 
in   direction :    all   rays   which  pass   through  the  central 


30 


OPTICAL    OUTLINES, 


point  of  the  lens  are  secondary  axes,  except  the  principal 
axis. 

11.  The  principal  focus,  /,  Fig.  10,  of  a  lens  is  the  point 
where  the  rays,  a  a,  that  were  parallel  before  they  trav- 
ersed the  lens  meet,  after  they  have  passed  through  it ;  the 
deviation  of  each  ray  varying  directh^  with  its  distance 
from  the  principal  axis.  Fig.  6. 

But  this  is  only  approximately  true.  In  an  ordinary  lens 
the  rays,  a,  Fig.  9,  which  traverse  the  margin  are  refracted 

Fig.  9. 


Spherical  aberration. 

more,  and  meet  sooner,  than  the  rays  [h)  which  lie  nearer  the 
axis  ;  and  the  result  is,  not  one  focus,  but  a  number  of  foci. 

Fig.  10. 


Foci  of  a  couvex  lens. 


"  Spherical  aberration"  increases  with  the  size  of  the  lens.  In 
the  eye  it  is,  to  a  great  extent,  prevented  by  the  iris,  which 
cuts  off  the  light  from  the  margin  of  the  crystalline  lens. 


OPTICAL     OUTLINES.  31 

If  parallel  rays  are  incident  from  the  side  toward/,  Fig. 
10,  they  will  be  focussed  at  f ,  at  the  same  distance  from 
the  lens  as  /;  hence  every  lens  has  two  principal  foci — 
anterior  and  posterior. 

12.  The  path  of  a  ray  passing  from  one  point  to  another 
is  the  same,  whatever  its  direction ;  the  path  of  the  ray 
h  h\  Fig.  10,  is  the  same, whether  it  pass  from  cf  to  c'f,  or 
in  the  contrary  direction. 

13.  From  §  7  it  follows  that  in  Fig.  10  the  angles  a  and 
a'  are  equal,  and  hence  the  ray  6,  diverging  from  cf,  will 
not  meet  the  axis  at  f,  but  at  c'f  ;  cf  and  cf  are  conju- 
gate points,  and  each  is  the  conjugate  focus  of  the  other. 
The  angle  a  or  a.'  remaining  the  same,  then  if  cf  be  fur- 
ther from  the  lens  cf  will  approach  it.  A  ray,  c,  directed 
toward  the  axis  will  be  focussed  at  c"f",  because  the 
angle  a"=za  ;  no  real  point  conjugate  to  c'f'  exists  :  but 
if  the  ray  start  from  c"f"  it  will,  on  taking  the  direction 
c,  appear  to  have  come  from  vf,  which  consequently  is  the 
virtual  focus   of  c"f",  see  §  6. 

Fig.  11. 


Foci  of  a  coucave  lens. 

14.  All  the  foci  of  concave  lenses  are  virtual.  In  Fig. 
11,  a,  parallel  to  the  axis,  is  made  divergent,  see  Fig.  7, 
its  virtual  focus  being  at  /;  similarly  cf  is  the  virtual  con- 
jugate focus  of  the  point  emitting  the  ray  h. 

15.  In  equally  biconvex  or  biconcave  lenses  of  crown- 
glass  the  principal  focus,  f,  is  at  the  centre  of  curvature  of 


32 


OPTICAL     OUTLINES. 


cither  surface  of  the  lens,  ?'.  e.,f=:r,  the  radius;  in  jdauo- 
convcx,  or  concave,  lenses /"=2r. 

16.  Images The  image  formed  by  a  lens  consists  of 

foci,  each  of  which  corresponds  to  a  point  on  the  object. 
Given  the  foci  of  the  boundary  points  of  an  object,  we 
have  the  position  and  size  of  its  image. 

In  Fig.  12  the  object  ah  lies  beyond  the  focus/.  From 
the  terminal  point  a  take  two  rays,  a  and  a',  the  former  a 
secondary  axis,  and  therefore  unrefracted  ;  the  latter  par- 

Fia.  12. 


Real  inverted  image  formed  by  a  convex  lens. 


allel  to  the  princi})al  axis,  and  therefore  passing  after  re- 
fraction through  the  principal  focus /^  These  two  rays, 
and  all  others  which  pass  through  the  lens  from  the  point 
a,  will  meet  at  a  the  conjugate  focus  of  a.  Similarly  the 
focus  of  the  point  h  is  found,  and  the  real  inverted  conju- 
gate image  of  a  6  is  formed  at  a  b.  The  relative  sizes  of 
a  h  and  a  b  vary  as  their  distances  from  the  lens. 

If  a  b  be  so  far  off  that  its  rays  are  virtually  parallel 
on  reaching  the  lens,  its  image  a  b  will  be  at/',  and  very 
small.  Ifaftbeat/,  its  rays  will  become  parallel  after 
refraction,  §§11  and  12,  and  form  no  image.  \i  a  b  lies 
between/,  or/^  and  the  lens,  the  rays  will  diverge  after 
refraction,  and  again  will  not  form  an  image,  see  Fig.  10, 
c"/". 


OPTICAL     OUTLINES. 


33 


But  in  the  last  two  cases  a  virtual  image  is  seen  by  an 
eye  so  placed  as  to  receive  the  rays.  In  Fig.  13  two  rays 
from  a  take  after  refraction  the  course  shown  by  a  and  a', 
virtually  meeting  at  A,  see  Fig.  10,  vf\  and  an  observer 
at  X  will  see  at  a  b  a  virtual^  magnified,  erect  image  of  a  b. 

Fig.  13. 


Virtual  erect  image  formed  by  a  convex  lens. 


The  enlargement  in  Fig.  13  is  greater  the  nearer  a  6  is 
to  /',  and  greatest  when  it  i<  at/'.  But  as  A  b  has  no 
real  existence,  its  apparent  size  varies  with  the  known  or 
estimated  distance  of  the  surface  against  which  it  is  pro- 
jected. A  uniform  distance  of  projection  of  about  12'' 
(30  cm.)  is  taken  in  comparing  the  magnifying  power  of 
different  lenses. 

When  a  5  is  at  /',  Fig.  13,  we  shall  find  on  trial  that 
the  image  a  b  can  be  seen  well  only  by  bringing  the  eye 
close  up  to  the  lens  ;  at  a  greater  distance  only  part  of  the 
image  will  be  seen,  and  this  part  will  be  less  brightly 
lighted.  This  is  important  in  direct  ophthalmoscopic  ex- 
amination. Thus  in  Fig.  14  an  observer  placed  anywhere 
between  the  lens  and  .r,  receivins-  rays  from  every  part  of 
a  b,  will  see  the  whole  image.  But  if  he  withdraw  to  y, 
his  eye  will  receive  rays  only  from  the  central  part  of  a  b, 
and  will  therefore  not  see  the  ends  of  the  object. 

It  is  easily  shown  by  similar    constructions   that  the 

9* 


34  O  P  T  1  C  A  L     0  U  T  L  1  N  E  S  . 

images  formed  by  concave,  lenses  are  always  virtual,  erect, 
and  diminished,  whatever  the  distance  of  the  object,  Fig. 
15.      Compare  Y\g.  11. 

Fig.  U. 


Virtual  image  ;  result  of  observer  varying  distance  oi  his 
eye  from  the  lens. 

17.  The  size  of  the  image,  w^hether  real  or  virtual,  varies 
with  (1)  the  focal  length  of  the  lens,  and  (2)  the  distance 
of  the  object  from  the  principal  focus. 

(1)  The  shorter  the  focus  of  the  lens,  the  greater  is  its 
effect,  or  the  "  stronger"  it  is  ;  the  refractive  power  of 
a  lens  varies  inversely  as  its  focal  length. 

Fig.  15. 


Image  formed  by  a  concave  lens. 

(2)  For  a  confer  lens,  the  image,  whether  real  or  virtual, 
is  larger,  i.  e.,  the  effect  greater,  the  nearer  the  object  is  to 
the  principal  focus,  whether  within  or  beyond  it. 

For  a  concave  lens,  the  image  is  smaller,  i.  e.,  the  effect 
greater,  the  further  the  object  is  from  the  lens,  w^hether 
within  or  beyond  the  focus. 


OPTICAL     OUTLINES. 


35 


18.  Prisms. — Any  object  viewed  through  a  prism  seems 
dis^placed  towards  the  edge  of  the  prism,  and  the  amount 
of  the  displacement  varies  directly  as  the  size  of  the 
refracting  angle,  §§  5  and  6.  The  eye  is  directed  towards 
the  position  which  the  object  now  seems  to  take;  and  this 


Fig. 


Fig.  17. 


Effect  of  prisms  in  lessening: 
convergence. 


Lenses  acting  as  prisms. 


effect  may  be  variously  utilized:  1.  To  lessen  the  conver- 
gence of  the  visual  lines  without  removing  the  object 
further  from  the  eyes.  In  Fig.  16  the  eyes,  r  and  l, 
are  looking  at  the  object,  ob,  wath  a  convergence  of  the 
visual  lines  represented  by  the  angle  a.  If  prisms  be  now 
added  with  their  edges  towards  the  temples,  they  deflect 
the  light,  so  that  it  enters  the  eyes  under  the  smaller  angle 
jS,  as  if  it  had  come  from  o6',  and  towards  this  point  the 
eyes  will  be  directed,  though  the  object  still  remains  at  ob. 
The  same  eff'ect  is  given  by  a  single  prism  of  twice  the 
strength  before  one  eye,  though  the  actual  movement  is 


36  O  P  T  T  C  A  L     0  i:  T  L  I  N  E  S  . 

then  limited  to  the  eve  in  question.  If  spectacle  lenses  be 
placed  so  that  the  visual  lines  do  not  pass  throuprh  their 
centres,  they  act  as  prisms;  though  the  strength  of  the 
prismatic  action  varies  with  the  power  of  the  lens  and 
the  amount  of  this  "  decentration,"  ^ee  §  9,  Figs.  6  and  7. 

Table  shoioing  the  Prismatic  Effect  of  Decenlering  Lenses 
{Maddox). 


Amount  of  Decentration  in  Millimetres. 


Lens. 

.5  mm. 

10  mm. 

15  mm. 

1   D     . 

17' 

35' 

52' 

2  D     . 

. 

35 

1°     9 

1°  43 

3  D     . 

52 

1      43 

2     34 

4  D     . 

. 

1-   10 

2      18 

3     26 

^^  D    . 

. 

1      43 

6     26 

5       9 

8  I)    . 

.... 

2     18 

4     35 

6     50 

In  Fig.  17  the  visual  lines  pass  outside  the  centres  of  the 
convex  lenses,  a,  and  inside  those  of  the  concave  lenses,  b. 
Each  pair  therefore  acts  as  a  prism  with  its  edge  outwards. 
2.  To  remove  double  vision  caused  In*  slight  degrees  of 
strabismus.  The  prism  so  alters  the  direction  of  the  rays 
as  to  compensate  for  the  abnormal  direction  of  the  visual 
line.  In  Fig.  18,  r  is  directed  towards  j;  instead  of  towards 
ob,  and  two  images  of  ob  are  seen,  see  Chapter  XXI.  The 
prism,  p,  deflects  the  rays  to  y,  the  yellow  spots,  and  single 
binocular  vision  is  the  result.  3.  To  test  the  strength  of  the 
ocular  muscles.  In  Fig.  19  the  prism  at  first  causes  diplopia 
by  displacing  the  rays  from  the  yellow  spot,  ?/,  of  ihe  eye  k, 
see  Chapter  XXI.  By  a  compensating  rotation  of  the  eye, 
cornea,  outwards,  shown  in  th^  figure  by  the  change  of  the 
tran.sverse  axis  from  1  to  2,  y  is  brought  inwards  to  the 
situation  of  im,  the  images  are  fused  and  single  vision 
restored  ;  the  effect  of  the  prism  is  overcome  b}-  the  action 


OPTICAL     OUTLINES. 


37 


of  the  external  rectus.  This  "  fusion  power  "  of  the  several 
pairs  of  muscles  may  be  expressed  by  the  strongest  prism 
that  each  pair  can  overcome.  The  fusion  power  of  the  two 
external  recti  is  represented  by  a  prism  of  about  8°  ;  that 
of  the  two  internals  bv  25°  to  50°  or  more  ;    that   of  the 


Fig.  18. 


Fig.  19. 


Diplopia  removed  by  prism. 


Prism  used  for  testing  strength 
of  muscle. 


superior  and  inferior  recti,  acting  against  each  other,  by 
only  about  3°.  4.  Feigned  hlindneas  of  one  eye  may  often 
be  exposed  by  means  of  the  diplopia,  unexpected  by  the 
patient,  produced  by  a  prism.  The  prism  should  be 
stronger  than  can  be  overcome  by  any  effort,  e.  g.,  8°  or 
10°,  base  upwards  or  downwards.  The  patient  is  best 
thrown  off  his  guard  if  the  prism  be  held  before  the  sound 
eye.  If  he  now  exclaims  that  he  sees  double,  he  must  of 
course  be  seeing  with  both  eyes. 


38 


OPTICAL    OUTLINES, 


19.  Refraction  of  the  eye The  eye  presents  three  re- 
fracting surfaces — the  front  of  the  cornea/ the  front  of  the 
lens,  and  the  front  of  the  vitreous ;  and  in  the  normally 
formed  or  emmetropic  eye  (E.),  with  the  accommodation 
relaxed,  the  principal  focus,  §  11,  of  these  combined  diop- 
tric media  falls  exactly  upon  the  layer  of  rods  and  cones 
of  the  retina  ;  i.  e.,  the  eye  in  a  state  of  accommodative  rest 
is  adapted  for  parallel  rays  The  point  at  which  the 
secondary  axial  rays,  see  §  10,  Fi;^.  8,  cross,  the  "  porterior 
nodal  point,"  v,  Fiir.  20,  lies,  in  the  normally  formed  eye, 
at  15  mm.  in  front  of  the  yellow  spot  of  the   retina,   and 

Fig.  20. 


Visual  angle  and  retinal  image.  06,  object ;  y,  visual  angle  ;  «,  nodal 
point  where  the  axial  rays  cross  ;  d,  distance  from  n  to  the  retina. 
The  position  of  the  retina  in  different  states  of  refraction  is  shown  by 
the  three  curved  lines  to  the  right,  H.  being  represented  by  the  line 
nearest  to,  and  N.  by  the  one  furthest  from,  w,  whilst  the  middle  thin 
line  shows  the  retina  in  E. 

very  nearly  coincides  with  the  posterior  pole  of  the  crys- 
talline lens.  The  angle  included  between  the  lines  joining 
n  with  the  extremities  of  the  object,  o6,  is  the  visual  angle,  v. 
If  the  distance,  d,  from  n  to  the  retina  remain  the  same, 
the  size  of  any  image,  Ini,  on  the  retina  will  depend  on  the 


'  The  posterior  surface  of  the  cornea  being  parallel  with  the  anterior 
causes  no  deviation,  and  the  aqueous  has  the  same  refractive  power  as 
the  cornea.  Hence  the  refractive  effect  of  the  cornea  and  aqueous  to- 
gether is  the  same  as  if  the  corneal  tissue  extended  from  the  front  of 
the  cornea  to  the  front  of  the  lens. 


O  P  T  I  C  A  L     O  U  T  L  I  N  E  S  .  39 

size  of  the  angle  u,  and  this  again  on  the  size  and  distance 
of  06.  But  if  the  distance,  d,  alters,  the  size  of  the  image, 
Im,  is  altered  without  any  change  in  v.  Now  the  length 
of  d  varies  with  the  length  of  the  posterior  segment  of  the 
eye ;  it  is  greater  in  myopia  (M.)  and  less  in  hypermetropia 
(H.) ;  and  hence  the  retinal  image  of  an  object  at  a  given 
distance  is,  as  the  figure  shows,  larger  in  myopia  and 
smaller  in  hypermetropia  than  in  the  normally  formed  eye. 
The  length  of  d  also  varies  with  the  position  of  n,  and  this 
is  influenced  by  the  positions  and  curvatures  of  the  several 
refractive  surfaces,  n  is  slightly  advanced  by  the  increased 
convexity  of  the  lens  during  accommodation,  and  much 
more  so  if  the  same  change  of  refraction  be  induced  by  a 
convex  lens  held  in  front  of  the  cornea :  hence  convex  lenses, 
by  lengthening  c/,  enlarge  the  retinal  image.  Concave  lenses 
put  n  further  back,  and,  by  thus  shortening  d,  lessen  the 
image.  If  the  lens  w^ich  corrects  any  optical  error  of  the 
eye  be  placed  at  the  "  anterior  focus"  of  the  eye,'  13  mm., 
or  half  an  inch,  in  front  of  the  cornea,  n  moves  to'  its 
normal  distance  (15  mm.)  from  the  retina,  whatever  the 
length  of  the  eye,  and  the  images  are  therefore  reduced  or 
enlarged  to  the  same  size  as  in  the  emmetropic  eye.  For 
definition  of  astigmatism  see  Chapter  XX. 

The  length  of  the  visual  axis,  a  line  drawn  from  the 
yellow  spot  to  the  cornea  in  the  direction  of  the  object 
looked  at,  is  about  23  mm.  The  centre  of  rotation  of  the 
eye  is  rather  behind  the  centre  of  this  axis,  and  6  mm. 
behind  the  back  of  the  lens.  The  focal  length  of  the 
cornea  is  31  mm.,  and  that  of  the  crystalline  lens  varies 
from  43  mm.  with  accommodation  relaxed,  to  33  mm. 
during  strong  accommodation. 

The  optical  conditions  of  clear  sight  are  as  follows : 
(1)  The  image  must  be  clearly  focussed  on  the  retina, 
i  e.,  the  retina  must  lie  exactly  at  the  focus  of  the  rays 

1  The  anterior  focus  is  the  point  where  rays  which  were  parallel  in 
the  vitreous  are  focussed  in  front  of  the  cornea. 


40  OPTICAL     OUTLINES. 

whicli  proceed  from  the  object  looked  at:  (2)  it  must  he 
formed  at  the  centre  of  the  yellow  spot,  Chapter  II,,  §  11: 
(3)  it  must  have  a  certain  size,  and  this  is  expressed  by 
the  size  of  the  corresponding  visual  angle,  v,  Fig.  20  ;  with 
good  iudoor  light  v  must  be  equal  to  at  least  5  minutes, 
j^^th  of  a  degree,  in  order  that  the  form  of  the  image  may 
be  perceived ;  an  object  subtending  any  smaller  angle, 
down  to  about  1  minute,  is  still  visible,  though  only  as  a 
point  of  light:^  (4)  the  cornea,  lens,  and  vitreous  must  be 
clear:  (5)  the  illumination  must  be  sufficient.  Influence 
of  the  piqnl :  Other  things  being  equal,  the  larger  the 
pupil  the  worse  is  the  sight,  definition  being  lessened  by 
the  spherical  aberration  caused  by  the  marginal  part  of 
the  lens.  Fig.  9.     See  Artificial  Pupil. 

The  smaller  the  pupil,  the  less  the  spherical  aberration  (p. 
30),  and,  ccet.  par.,  the  better  the  V.  Also,  the  smaller  the 
pupil  tlie  less  is  the  accommodation  needed  for  near  vision. 
If  the  pupil  be  so  small  as  to  subtend  an  angle,  "angle  of  diver- 
gence," of  not  more  than  5  minutes  with  any  point  on  the 
object,  the  object  will  be  clearly  seen  without  accommodation. 
By  calculation  it  appears  that  if  the  pupil  had  a  diameter  = 
0.66  mm.,  it  would  subtend  an  angle  of  divergence  of  5  minutes 
at  about  0.5  m.  (18");  i.  e.,  with  a  pupil  of  0.66  mm.  print 
should,  in  a  good  light,  be  clearly  seen  at  18''  without  any 
accommodation.  That  this  is  true  may  be  proved  by  looking 
at  fine  print  through  a  hole  of  the  above  size  in  a  thin  card 
held  as  close  as  possible  to  the  eye. 

Numeration  of  spectacle  lenses. — Some  system  of  num- 
bering is  required  w^hich  shall  indicate  the  refractive  power 
of  the  lenses  used  for  spectacles.  Two  systems  are  current. 
In  the  first  system,  which  was  till  lately  universal,  the  unit 
of  strength  is  a  strong  lens  of  f  focal  length.  As  all  the 
lenses  used  are  weaker  than  this,  their  relative  strengths 
can  be  expressed  only  by  using  fractions.    Thus,  a  lens  of 

1  In  bright  light,  as  in  the  open  air,  the  minimum  visual  angle  is 
coiisiderahlv  less  than  5  minutes. 


OPTICAL     OUTLINES.  41 

2''  focus,  being  half  as  strong  as  the  unit  (§17,  1),  is  ex- 
pressed as  -^ ;  a  lens  of  10^'  focus  is  J^  ;  of  20^'  focus  ^V  5 
and  so  on.  The  objections  are,  that  fractions  are  incon- 
venient in  practice  ;  that  the  intervals  between  the  succes- 
sive numbers  are  very  unequal ;  and  that  the  length  of  the 
inch  is  not  the  same  in  all  countries,  so  that  a  glass  of 
the  same  number  has  not  quite  the  same  focal  length  when 
made  by  the  Paris,  English,  and  German  inches  respect- 
ively.^ In  the  second  system,  which  has  almost  displaced 
the  old  one,  the  metrical  scale  is  used,  the  unit  is  a  weak 
lens  of  1  metre  (100  cm.)  focal  length,  known  as  a  dioptre 
(D),  and  the  lenses  differ  by  equal  refractive  intervals.  A 
lens  twice  as  strong  as  the  unit,  with  a  focal  length  of  half 
a  metre,  50  cm.,  is  2  dioptres  (2  D),  a  lens  of  ten  times  the 
strength,  or  one-tenth  of  a  metre  focus,  10  cm.,  is  10  D,  and 
so  on.  The  weakest  lenses  are  0.25,  0.5,  and  0.T5  D,  and 
numbers  differing  by  0.5  or  0.25  D  are  also  introduced 
between  the  whole  numbers.  A  slight  inconvenience  of 
the  metrical  dioptric  system  is  that  the  number  of  the  lens 
does  not  express  its  focal  length.  This,  however,  is  ob- 
tained by  dividing  100  by  the  number  of  the  lens  in  D  ; 
thus  the  focal  length  of  4  D  =  ^l'=  25  cm.  If  it  be  desired 
to  convert  one  system  into  the  other,  this  can  be  done,  pro- 
vided that  we  know  what  inch  was  used  in  making  the  lens 
whose  equivalent  is  required  in  D.  The  metre  is  equal  to 
about  37^'  French  and  39''  English  or  German  ;  a  lens  of 
:i6''  French  (No.  36  or  Jg  old  scale),  or  of  40''  English  or 
German  (No.  40  or  J^),  is  very  nearly  the  equivalent  of  1 
D.  A  lens  of  6"  French  {^=z^%)  will  therefore  be  equal 
to  6  D;  alensof  18"French(Jg=r32e)  =  2  D,  etc.;  a  lens 
of  4  0  =  3%=^,  i.  e.,  a  lens  of  9"  French,  etc. 

The  following  lenses  are  used  for  spectacles,  and  are, 
therefore,  necessary  in  a  complete  set  of  trial  glasses.     The 

^  1"  English  =  25.3  mm.,  1''  Frenc]i=2T  mm.,  1"  Austrian  =26.3 
mm..  1"  Prussian  =  26.1  mm. 


42 


OPTICAL     OUTLINES 


first  column  gives  the  number  in  D,  the  second  the  focal 
length  in  centimetres,  the  third  the  approximate  numbers 
on  the  French  inch  scale,  the  denominator  of  each  fraction 
showing  the  focal  length  in  French  inches.  It  will  be  seen 
that  some  metrical  lenses  have  no  exact  equivalents  on  the 
inch  system.  In  this  table,  and  throughout  the  book,  con- 
vex lenses  are  indicated,  according  to  custom,  by  the  -f 
sign  ;  concave  lenses  by  the  —  sign. 

Prisms  are  numbered  by  their  angle  of  refraction,  which 
is  (p.  27)  about  double  the  angle  of  deviation;  another 
method  is  to  name  the  prism  by  the  number  of  degrees  of 
deviation  which  it  produces ;  to  indicate  that  degrees  of 
deviation  are  meant  the  letter  d  should  be  used ;  thus 
prism  2°  d  indicates  that  the  prism  produces  a  deviation  of 
2°  (Maddox).  Prisms  cannot  be  used  as  spectacles  of  a 
greater  strength  than  about  4°  d  in  each  eye  on  account  of 
the  dispersi3n  of  light  which  they  produce. 


1. 

2. 

3. 

1. 

1 

2. 

3. 

D. 

Focal 

No.  and 

D. 

Focal 

No.  and 

(Dioptres.) 

Length  in 

Focal  Length 

:   (Dioptres.) 

Length  in 

Focal  Length 

cm. 

in  Paris 
inches. 

! 

cm. 

in  Paris 
inches. 

0.25 

400 

5 

20 

1 
T 

0.5 

200 

tV 

5.5 

18 

0.75 

133 

sV 

6 

16 

i 

1 

100 

3V 

7 

14 

hi 

1.25 

80 

sV 

1          8 

12.5 

1.5 

66 

^v 

i           9 

11 

i 

1.75 

57 

] 

22 

10 

10 

sX 

2 

50 

tV 

i        il 

9 

2.25 

44 

tV 

i        12 

8.3 

JL 
3 

2.5 

40 

A 

13 

7.7 

2.75 

36 

t'3 

14 

7 

hi 

3 

33 

tV 

15 

6.7 

2% 

3.5 

28 

tV 

16 

6.2 

hA 

4 

25 

i 

18 

5.5 

4.5 

22 

I 

20 

5 

CHAPTER  II. 

EXTERNAL    EXAMINATION    OF    THE    EYE. 

(1)  To  detect  irregularity  of  the  corneal  surface,  the 
patient  faces  the  window  and  follows  with  his  eyes  an 
object,  e.  g.,  the  uplifted  finger,  held  about  18'^  from  him 
and  moved  slowly  in  different  directions.  The  image  of 
the  window  reflected  from  the  cornea  will  become  distorted 
or  broken  as  it  passes  over  any  irregularity,  such  as  an 
abrasion  or  ulcer. 

(2)  To  estimate  the  tension  of  the  eyeball  (T.)  :  The 
patient  looks  steadily  down  and  gently  closes  the  eyelids ; 
the  observer  then  makes  light  pressure  on  the  globe 
through  the  upper  lid,  alternately  with  a  finger  of  each 
hand  as  in  trying  for  fluctuation,  but  much  more  deli- 
cately. The  finger-tips  are  placed  very  near  together,  and 
as  far  back  over  the  sclerotic  as  possible,  not  over  the 
cornea.  The  pressure  must  be  gentle,  and  be  directed 
vertically  doicnicards,  not  backwards.  It  is  best  for  each 
observer  to  keep  to  one  pair  of  fingers,  not  to  use  the  index 
at  one  time  and  the  middle  finger  at  another.  Patient  and 
observer  should  always  be  in  the  same  relative  position, 
and  it  is  best  for  both  to  stand  and  face  one  another. 
Alwayscompare  the  tension  of  the  two  eyes.  Be  sure  that 
the  eye  does  not  roll  upwards  during  examination,  for  if 
this  occur  a  wrong  estimate  of  the  tension  may  be  formed 
Some  test  both  eyes  at  once  with  two  fingers  of  each  hand. 
Normal  tension  is  expressed  by  T.  n.  Recognizable  in- 
crease and  decrease  are  indicated  by  the  -|-  or  —  sign, 
followed  by  the  figure  1,  2,  or  3.  Thus  T.-fl  means  de- 
cided increase  ;  T.-|-2,  greater  increase,  but  eye  can  still 
be  indented  ;  T.-|-3,  eye  very  hard,  cannot  be  indented  by 


44   EXTERNAL  EXAMINATION  OF  THE  EYE. 

moderate  pressure  ;  T. — 1  — 2  — 3  indieate  suceessivo  de- 
grees of  lowered  tension.  A  note  of  interrogation  (T.?-|- 
or  ? — )  for  doubtful  eases,  and  T.  n.  for  normal,  give  nine 
degrees  which  may  be  usefulh^  distinguished.  Even  good 
observers  sometimes  differ  as  to  the  minor  changes  of  ten- 
sion. Apart  from  variations  in  delicacy  of  touch,  it  is  to 
be  remembered  that  eyes  deeply  set  in  the  orbits  are  more 
difficult  to  test,  and  that  T.  in  a  few  cases  really  does 
change  at  short  intervals,  e.  g.,  within  half  an  hour.  In- 
crease in  the  rigidity  of  the  sclerotic,  which  often  occurs  in 
old  age  ;  or  in  its  thickness,  as  the  result  of  disease,  may 
increase  the  apparent  tension,  though  the  internal  pressure 
may  be  normal  or  even  too  low.  When  an  eye  contains 
bone  it  feels  like  wood  covered  with  w^ash-leather.^ 

(3)  The  field  of  vision  (F.),  properly,  of  indirect  vision, 
is  the  entire  surface  from  which,  at  a  given  distance,  light 
reaches  the  retina,^  the  eye  being  stationary.  Fig.  21.  If 
each  part  of  the  field  be  equidistant  from  the  part  of  the 
retina  to  which  it  corresponds,  the  field  will  be  hemispher- 
ical, with  its  inner  or  concave  surface  towards  the  eye  ;  it 
may,  however,  be  projected  on  to  a  flat  surface,  and  for 
many  clinical  purposes  this  is  sufficient.  For  roughly  test- 
ing the  field,  e.  g.,  in  a  case  of  chronic  glaucoma,  or  of 
atrophy  of  optic  nerve,  or  of  hemianopsia,  the  following  is 
generally  enough.  Place  the  patient  with  his  back  to  the 
window  ;  let  him  cover  one  eye,  and  look  steadily  at  your 
eye  or  nose,  as  a  centre,  from  a  distance  of  18'^  or  2'.  Then 
hold  up  your  hands  with  your  fingers  spread  out  in  a  plane 
with  your  face,  and  ascertain  the  greatest  distance  from 
the  central  point  at  which  they  remain  visible  vrhen  moved 

^  Plates  of  bone,  sometimes  joined  so  as  to  form  a  cup,  are  not  uncom- 
monly found  on  the  inner  (retinal)  surface  of  the  choroid  in  eyes  which 
have  been  long  blind  from  irido-choroiditis. 

■^  Strictly  "  the  percipient  part  of  the  retina."  It  now  seems  estab- 
lished that  the  most  peripheral  zone  of  the  retina  is  not  sensitive  to 
light.     (Landolt.) 


EXTERNAL     EXAMIXATION     OF     THE     EYE.       45 

in  various  directions — up,  down,  in,  out,  and  diagonally. 
The  patient  must  look  steadily  at  the  face,  and  not  allow 
his  eye  to  wander  after  the  moving  fingers. 

Fig.  21. 


Field  of  vision  with  radius  of  12",  projected  up  to  45°  on  to  a  flat  surface 
two  feet  square,     f,  fixation  spot. 

A  more  exact  method  is  to  make  the  patient  gaze,  with 
one  eye  covered,  at  a  white  mark,  the  "  fixation  spot,"  on  a 
large  blackboard  at  a  distance  of  \2"  or  18^',  and  to  move 
a  piece  of  white  chalk  set  in  a  long  black  handle,  from 
various  parts  of  the  periphery  towards  the  fixation  spot, 
until  the  patient  exclaims  that  he  sees  something  white. 
If  a  mark  be  made  on  the  board  at  about  eight  such  peri- 
pheral points,  a  line  joining  them  will  give,  with  fair  accu- 
racy, the  boundary  of  the  visual  field  if  this  be  not  larger 
than  45^  in  any  direction;  but  beyond  that  angle  the 
object,  if  on  a  flat  surface,  will  be  much  too  far  from  the 
eye  to  make  the  test  accurate,  see  Fig.  21.  A  true  map, 
unless  the  field  be  much  contracted,  can  be  made  only  by 
means  of  an  instrument,  the  perimeter,  which  consists 
essentiallv   of   an   arc   marked   in   degrees,  and  movable 


46       EXTERNAL    EXAMINATION     OF     THE     EYE. 

around  a  central  pivot  on  which  the  patient  fixes  his  gaze. 
Thus  measured  the  field  covers  a  somewhat  oval  portion  of 
the  hemisphere,  the  smaller  end  being  upwards  and  in- 
wards, Fig.  22.     From  the  fixation  point  it  extends  90°  or 

Fig.  22. 


Field  of  vision  of  right  eye  as  projected  b}'  the  patient  on  the  inner 
surface  of  a  hemisphere,  the  pole  of  which  forms  the  object  of  regard 
(half-diagrammatic).  T.  temporal,  N,  nasal  side,  w,  boundary  for  white 
B,  for  blue  ;  r,  for  red  ;  g,  for  green.     (Landolt.) 

more  in  the  outward  direction,  but  only  about  65°  or 
rather  less  inwards,  upwards,  and  downwards.  The  visual 
fields  of  the  two  eyes  overlap  only  at  their  inner  and 
central  parts,  so  that  binocular  vision  is  impossible  in  the 
outer  part  of  the  field,  Fig.  23. 

(4j    Color-perception   is  best   expressed  by  the  power 


EXTERNAL  EXAMINATION  OF  THE  EYE.   47 

of  discriminating  between  various  colors  without  naming 
them.  The  best  test-objects  are  a  series  of  skeins  of 
colored  wool,  or,  for  pocket  use,  smaller  strips  of  colored 
paper,  or  colored  stuffs  A  color-blind  person  will  expose 
his  defect  by  placing  together,  or  "confusing"  as  similar, 
certain  colors,  usually  mixed  tints,  which  to  the  normal 
eye  appear  quite  different.  The  set  of  wools  now  in  com- 
mon use  was  introduced  by  Professor  Holmgren,  of  Upsala.^ 

Fig.  23. 


Binocular  field  of  vision.  The  white  part  is  the  portion  common  to 
the  two  eyes,  i.  e  ,  possessing  binocular  vision  ;  the  shaded  (temporal) 
part  shows  the  portion  in  which  binocular  vision  is  wanting.  F,  fixa- 
tion point.  The  two  blind  spots  are  marked  by  round  spots.  (Simpli- 
fied, after  FiJrster.) 

See  Appendix.  Acquired  color-blindness  (from  atrophy 
of  the  optic  nerves)  may  often  be  detected  quite  well  by 
asking  the  names,  if  the  patient  has  been  well  trained  in 
colors.  But  for  the  congenitally  color-blind  the  "  confu- 
sion test,"  without  names,  is  far  better  :  first,  because  such 
persons  can  often  distinguish  ordinary  colored  objects  from 
one  another  by  differences  of  shade,  i.  e.,  by  differences  in 
the  quantity  of  white  light  which  they  reflect,  and  hence 
they  escape  detection  unless  tested  with  a  large  series  of 
different  colors  in  many  shades,  some  of  which  shades,  con- 
taining equal  quantities  of  white,  will  look,  to  them,  exactly 

1  De  la  Cecite  des  Couleurs,  etc.,  1877. 


48   EXTERNAL  EXAMINATION  OF  THE  EYE. 

alike;  and  secondly,  though  such  persons  often  use  the 
names  for  colors  freely,  the  words  do  not  convey  the  same 
meaning'  to  them  as  to  those  with  normal  color-sense,  and 
hopeless  confusion  results  from  an  examination  so  made. 
For  details  see  Chapter  XY.  and  Supplement. 

(5)  Testing-  the  acuteness  of  sight By  acuteness  of 

sight  (Y.  or  S.)  is  meant  the  power  of  distinguishing/orm, 
and,  as  commonly  used,  the  term  refers  only  to  the  centre 
of  the  visual  field,  the  peripheral  part  of  the  retina  having 
a  very  imperfect  power  of  distinguishing  form  and  size. 
Y.  varies  considerably  in  different  persons  whose  eyes  are 
normal.  It  is  said  to  diminish  some w'' at  in  old  age,  with- 
out disease  of  the  eye  (Donders)  The  standard  taken  as 
normal  is  the  power  of  distinguishing  square  letters  that 
subtend  a  visual  angle  of  5  minutes,  Fig.  20  and  p.  40, 
the  limbs  of  which  are  of  uniform  thickness,  each  limb 
subtending  an  angle  of  1  minute  (Snellen's  Test-types). 
Rays  forming  so  small  an  angle  are  very  nearly  parallel, 
and  may  be  considered  as  coming  from  an  object  at  an 
infinite  distance.  The  types  are  made  of  various  sizes,  each 
being  numbered  according  to  the  distance,  in  feet  or 
metres,  at  which  it  subtends  a  visual  angle  of  5  minutes. 
Thus,  No.  6  subtends  this  angle  at  6  m.,  No.  3  at  3  m..  No. 
1  at  1  m.,  etc.  Nnmerically,  acuteness  of  vision  is  ex- 
pressed by  a  fraction,  of  which  the  denominator  is  the 
numl:)er  of  the  type  D,  and  the  numerator  the  greatest  dis- 
tance (d)  at  which  it  can  be  read,  Y=-:  if  No.  G  is  read 
at  6  m.  -=  [;  or  1,  i.  e.,  Y  is  normal ;  if  onlv  No.  18  can 
be  read  at  6  m.  ^-=r%  ;  if  only  60,  then  |  =  (fo-  ^^J  dis- 
tance greater  than  about  3  m.  may  be  selected  for  this  test ; 
i.  e.,  No.  3  read  at  3  m.,  or  No.  5  at  5  m.,  g  iierally  shows  the 
same  acuteness  as  No.  6  read  at  6  m.  But  at  distances  less 
than  3  m.  the  accommodation  comes  into  play,  and  the 
illumination  is  often  brighter  ;  hence  No  1  at  1  m.  (|)  does 


EXTERNAL     EXAMINATION     OP     THE     EYE.       49 

not  necessarily  show  the  same  state  of  sight  as  Xo.  6  at  G  m. 
(^).  It  is  therefore  best,  by  recording  the  fractions  unre- 
duced, to  indicate  the  distance  at  which  the  test  was  used. 
For  testing  near  vision,  Snellen's  types  are  thought  by 
some  to  be  practically  inferior  to  those  of  Jaeger  and 
others,  in  which  the  letters  have  the  form  and  proportions 
found  in  ordinar}'  type.  See  Appendix.  If  Y.  be  very  bad, 
less  than  -g%  or  j\,  it  may  be  expressed  accurately  enough 
by  noting  the  distance  at  which  the  outspread  fingers  can 
be  counted  when  exposed  to  a  good  light  and  against  a 
dark  background.  Below  this  point  we  can  still  distin- 
guish good  from  bad,  or  uncertain,  perception  of  light  and 
shade  (p.  /.),  by  alternately  exposing  and  shading  the  eye 
■w'lth  the  hand,  without  touching  the  face. 

(6)  Accommodation  (Ace.)  is  tested  clinically  by  meas- 
uring the  nearest  point  (punctum  proximum,  p.)  at  which 
the  smallest  readable  type  (Snellen's  0.5  or  Jaeger's  1)  can 
be  clearly  seen.     The  region  of  accommodation  is  the  space 

Fig.  24. 


Accommodation  represented  b\'  a  convex  lens. 

in  which  it  is  available  (see  Presbyopia).  The  amplitude, 
ptoicer,  or  range  of  Ace.  is  expressed  in  terms  of  the  convex 
lens  whose  focal  length  =  the  distance  from  the  cornea^ 
to  p.,  this  being  the  lens  which  adapts  Y.  in  an  eye  with- 


*  Strictly,  from  a  point  about  "i^'' in  front  of  the  cornea,  sines  the  glass 
cannot  be  placed  upon  the  eyeball. 

3 


50      EXTERNAL     EXAMINATION    OF    THE     EYE. 

out  Acc.  from  tho  farthest  point  of  distinct  vision  (jiunctum 
remotiHsimum,  r.)  to  p.  Tlius  in  Fife.  24  let  73  be  at  10  cm. : 
if  Acc.  be  then  rehixed,  i.  e.,  the  eye  be  adapted  for  parallel 
rays,  the  rays  from  p  will  be  focussed  at  c.  f.,  behind  the 
retina ;  but  Y.  will  again  be  clear  at  10  cm.  if  a  lens,  I,  of 
10  cm.  focus  (=10  D.,  see  p.  41)  be  held  close  to  the 
cornea ;  because  rays  from  p  will  be  made  parallel  by  I 
before  entering  the  eye  (Chapter  I.,  §§  11  and  12)  and  will 
therefore  be  focussed  on  the  retina. 

Convergence  of  the  visual  axes  upon  a  point  at  any 
given  distance  is  usually  associated  with  accommodation 
for  the  same  distance.  The  t^vo  functions  can,  however,  be 
somewhat  dissociated  to  an  extent  that  varies  with  age  and 
in  different  persons;  i.  e.,  Acc.  can  be  either  relaxed  a 
little  or  increased  a  little,  without  changing  any  given 
degree  of  convergence  ;  this  independent  portion  is  know^n 
as  the  7'eJative  accommodation. 

(7)  The  pupils  are  to  be  examined  as  to  their  equality, 
size  in  ordinary  light,  mobility,  and  form.  The  pupils  are 
often  large  and  inactive,  and  sometimes  oval,  in  amaurotic 
patients,  in  glaucoma,  and  in  paralysis  of  the  circular 
fibres  of  the  iris,  supplied  by  the  third  nerve.  They  may 
be  too  large,  though  active,  in  myopia  and  in  conditions  of 
defective  nerve  tone.  Wide,  recent  dilatation  of  one  pupil 
or  both,  wdth  dimness  of  sight  but  without  ophthalmoscopic 
signs  of  disease,  is  usually  traceable  to  atropine  or  bella- 
donna, used  by  accident  or  design.  When  very  small  the 
pupil  is  seldom  quite  round. 

The  centre  of  the  pupil  usually  lies  a  little  to  the  nasal 
side  of  the  corneal  centre.*  The  pupils  should  be  round 
and,  w^hen  equally  lighted,  equal  in  size.  When  one  eye 
is   shaded    its  pupil  should    dilate  considerably,  and  on 

'  This  eccentricity  varies  in  degree  and  exact  position  in  different 
persons.     Coinpare  Irregular  Astigmatism. 


EXTERNAL  EXAMINATION  OF  THE  EYE.   51 

exposure  contract  quickly  to  its  former  size,  ''direct  reflex 
action ;"  during  this  trial  the  other  pupil  will  act,  but  to  a 
much  less  extent,"  indirect  reflex  action^  The  pupils  con- 
tract when  the  gaze  is  directed  to  a  near  object,  say  G" 
distant,  i.  e.,  during  accommodation  and  convergence,  and 
dilate  in  looking  at  a  distant  object ;  but  the  range  of  this 
''  associated  action  '*  is  much  less  than  that  of  the  reflex 
action.  The  pupil  dilates  when  painful  impressions  are 
made  on  the  sensory  nerves  of  the  skin,  e.  g.,  by  the  fara- 
daic  brush  or  by  pricking  with  a  pin.  The  pupils  may  be 
motionless  to  light  and  shade  from  iritic  adhesions  (Chap- 
ter YIII.)  or  from  atrophy  of  the  iris  in  glaucoma  or  other 
local  disease  ;  such  conditions  should  be  carefully  noted  or 
excluded.  Reflex  action  is  lost  when  the  eyes  are  blind 
from  disease  of  the  optic  nerves  or  retinae  ;  if  only  one  eye 
be  blind,  the  direct  action  of  the  pupil  is  lost  in  that  eye, 
but  (unless  there  l>e  disease  of  the  third  nerve)  its  indirect 
action  is  much  increased.  When  one  eye  is  blind  the  pupil 
is  often  rather  larger  than  that  of  the  other.  Reflex  action 
may  also  l)e  lost  without  any  affection  of  sight,  and  icithout 
loss  of  associated  action.     Chapters  XXI.  and  XXIII. 

Permanent  inequality  of  the  pupils  without  disease,  either 
of  eyes  or  of  nervous  system,  is  rare,  but  temporary  dilata- 
tion of  one  pupil  is  not  uncommon.  When  very  active 
pupils  are  suddenly  exposed  after  being  shaded  they  often 
oscillate  for  a  few  seconds  before  settling,  and  finally  re- 
main a  little  larger  than  at  the  first  moment  of  exposure. 
Considerable  differences  in  the  action  of  the  pupils,  both  in 
9'ange and  rapidity,  are  compatible  with  health  ;  in  general, 
however,  the  pupils  become  smaller  and  lose  both  in  range 
and  rapidity  of  action  with  advancing  years:  atropine  also 
often  causes  only  partial  dilatation  in  old  people.  Marked 
inactivity,  with  small  size,  should  excite  suspicion  of  spinal 
or  cerebral  disease  (Chapter  XXIII.).  The  pupils  are 
smaller  whenever  the  iris  is  consrested,  whether  this  be  a 


52   EXTERNAL  EXAMINATION  OF  THE  EYE. 

merely  local  condition,  e.  g.,  in  abrasion  of  cornea,  or  form 
part  of  a  more  general  congestion,  as  in  typhus  fever 'and 
in  plethoric  states,  or  be  caused  by  venous  obstruction,  as 
in  mitral  regurgitation  and  bronchitis.  They  are  large  in 
anaemia,  in  conditions,  such  as  aortic  insufficiency,''  where 
the  systemic  arteries  are  badly  filled,  and  during  rigors ; 
irritation  of  the  sympathetic  nerve  in  the  neck  is  an  occa- 
sional cause  of  m3^driasis.^     Chapter  XXI. 

(8)  Note  the  color  of  the  iris,  and  compare  it  with  that 
of  the  fellow-eye.  Occasionally  the  two  irides,  although 
healthy,  differ  in  color,  one  being  blue  or  gray,  the  other 
brown  or  greenish  ;  more  frequently  a  large  sector-shaped 
patch  of  dark  color  occupies  part  of  the  iris  of  one  eye. 
Small  pigmented  spots  are  often  seen  on  the  iris.  If  the 
iris  of  an  inflamed  eye  look  greenish,  that  of  its  fellow 
being  blue,  we  should  suspect  iritis;  and  if  the  iris  of  a 
defective  eye  be  different  from  its  fellow,  some  morbid 
change  should  be  suspected.     Chapter  YIII. 

(9)  Information  derived  from  the  bloodvessels  visible 

on  the  surface  of  the  eyeball Three  systems  of    vessels 

have  to  be  considered  in  disease  ;  but  most  of  them  are  too 
small  to  be  easily  seen  in  health.  (1)  The  vessels  proper 
to thecon^unci'iva,, posterior conjinictival  vessels,  in  which  it 
is  not  important  to  distinguish  between  arteries  and  veins, 
Fig.  25,  Post.  Conj.,  and  Fig.  26.  (2)  The  anterior  ciliary 
vessels,  lying  in  the  subconjunctival  tissue ;  their  perforating 
arterial  branches  supply  the  sclerotic,  iris,  and  ciliary  body, 
their  veins  receive  blood  from  Schlemm's  canal  and  the 
ciliary   body.     The  perforating  branches  of  the  arteries, 

1  The  small  pupil  of  typhus  and  the  frequently  large  pupil  of  typhoid 
are  ascribed  by  Murchison  to  the  diflFerences  in  the  vascularity  of  the 
iris  in  these  diseases.     Continued  Fevers,  p.  S-tl. 

^  Medical  Examiner,  March  2,  1879. 

3  This  condition  seems  to  be  rare  ;  I  can  hear  but  little  of  it  in  the 
experience  of  my  medical  friends. 


EXTERNAL  EXAMINATION  OP  THE  EYE.   53 

Fig.  25,  A,  are  seen  in  health  as  several  comparatively  large 
tortuons  vessels  which  stop  short  about  -^^"  or  \"  from  the 
corneal  margin,  Fig.  27  ;  their  very  numerous,  small,  non- 

FiG.  25. 


strr^ 


Vessels  of  the  front  of  the  eyeball,  cm.  Ciliary  muscle.  Ch.  Choroid. 
iicl.  Sclerotic.  F.  V.  Vena  vorticosa.  I.  Marginal  loop-plexus  of  cornea. 
Ant.  and  Post.  Conj.  Anterior  and  posterior  conjunctival  vessels.  Ant. 
Cil.  A.  and  V.  Anterior  ciliary  arteries  and  veins.  (Simplified  and 
altered  from  Leber.) 

perforating  (episcleral)  branches  are  invisible  in  health, 
but  form,   when   distended,  a  pink  zone  of  fine,  nearly 


64   EXTERNAL  EXAMINATION  OF  THE  EYE. 

straight,  very  closely-set  vessels  round  the  cornea,  Fig.  25, 
A,  and  Fig.  28,  "ciliary  congestion,"  "circumcorneal  zone," 
see  Iritis  and  Diseases  of  Cornea  ;  the  perforating  veiiis  are 
very  small,  but  more  numerous  than  the  perforating  arte- 

FiG.  26. 


Conjunctival  congestion,  engorgement  of  the  posterior  conjunctival 
arteries  and  veins,     (After  Guthrie.) 

Fig.  27. 


Congestion  of  the  perforating  branches  of  the  anterior  ciliary  arteries. 
(Dalrymple.)  The  dusky  spots  at  the  seats  of  perforation  are  often  seen 
in  dark-complexioned  persons. 

ries,  Fig.  25,  v,  and  their  episcleral  twigs  form  a  closely- 
meshed  network,  Fig.  29.  (3)  The  vessels  proper  to  the 
margin  of  the  cornea  and  immediately  adjacent  zone  of 
conjunctiva,  anteinor  conjunctival  vessels,  and  their  loop 
plexus  on  the  corneal  border,  Fig.  25,  /,  and  Fig.  53 ;  by 


EXTERNAL  EXAMINATION  OF  THE  EYE 


55 


these  numerous  minute  branches,  which  are  offshoots  of 

the  anterior  ciliary  vessels,  Systems  1  and  2  anastomose. 

Speaking  generally,  congestion  composed  of  ( 1 )  tortuous, 

bright-red  (brick-red)  vessels  (System  I)  moving  with  the 


Fig.  28. 


Fig.  29. 


*'  Ciliary  congestion,"  engorge- 
ment of  episcleral  twigs  of  ante- 
rior ciliary  arteries.  (After  Dai- 
ry mple.) 


Congestion  of  anterior  ciliary 
veins,  episcleral  venous  plexus. 
(After  Dalrymple.) 


conjunctiva  when  it  is  slid  over  the  globe,  and  least  intense 
just  around  the  cornea.  Fig.  26,  indicates  a  pure  conjuncti- 
vitis (ophthalmia),  and  is  usually  accompanied  by  muco- 
purulent or  purulent  discharge.  (2)  A  zone  of  pink  con- 
gestion surrounding  the  cornea,  and  formed  by  small, 
straight,  parallel  vessels,  closely  set,  radiating  from  the 
cornea,  and  not  moving  with  the  conjunctiva,  anterior 
ciliary  arterial  twigs,  Fig.  28,  points  to  irritation  or  in- 
flammation of  the  cornea,  or  iris.  A  more  scanty  zone  of 
dark  or  dusky  color,  Fig.  29,  which,  when  severe,  is  finely 
reticulated,  episcleral  venous  plexus,  often  points  to  glau- 
coma, but  may  accompany  other  diseases,  especially  in  old 
people.  Congestion  in  the  same  region,  more  deeply  seated, 
and  of  a  peculiar  lilac  tint,  especially  if  unequal  in  different 
parts  of  the  zone,  shows  cyclitis  or  deep  scleritis.  (3)  Con- 
gestion in  the  same  zone,  and  also  composed  of  small 
vessels,  but  superficially  placed,  bright  red,  and  often  en- 


56   EXTERNAL  EXAMTNATTON  OF  THE  EYE. 

croaching  a  little  on  the  cornea,  anterior  conjunctival  ves- 
sels and  loop  plexus  of  cornea,  Fig.  53,  shows  a  tendency 
to  irritable  but  often  superficial  corneal  inflammation. 
Localized  or  fasciculated  congestion  generally  points  to 
phlyctenular  disease,  Figs.  45  and  46.  Although  in  the 
severe  forms  of  all  acute  diseases  of  the  front  of  the  eye 
these  types  of  congestion  are  usually  mixed  and  but  im- 
perfectly distinguishable,  much  information  may  often  be 
derived  from  attention  to  the  leading  forms  described. 

(10)  The  mobility  of  the  eyeball  may  be  impaired  in 
any  or  every  direction,  and  in  any  degree.  Commonly  only 
one  eye  is  affected.  First,  to  test  the  lateral  and  vertical 
movements,  direct  the  patient  with  both  eyes  open  to  look 
successively  towards,  or  follow  a  pencil  or  finger  moved  in, 
each  of  the  four  directions,  up,  down,  right,  and  left;  next, 
to  test  the  convergence  power,  he  looks  at  the  object  held 
vertically  in  the  middle  line,  rather  below  the  horizontal, 
and  gradually  approached  from  2'  to  about  6^^  In  each 
position  we  must  notice  both  eyes  ;  thus,  when  the  patient 
looks  to  his  right  we  have  to  note  the  outward  movement  of 
his  right  and  the  inward  movement  of  his  left.  The  fixed 
marks  for  the  inward  and  outward  movements  are  the  inner 
and  outer  canthi,  and  as  the  apparent  range  of  movement 
judged  in  this  way  varies  a  little  in  different  people,  the 
corresponding  movements  of  the  two  eyes  should  always  be 
compared.  In  lookingstrongly  outwards  the  corneal  margin 
does  not  in  all  persons  quite  reach  the  outer  canthus,  but  it 
should  always  reach  the  inner  canthus  during  inward  rota- 
tion. In  children  and  stupid  people  the  movements  are  often 
defective  from  inattention.  In  very  myopic  eyes  the  move- 
ments are  somewhat  defective  in  all  directions.  The  vertical 
movements  are  best  shown  by  noting  the  position  of  the  cor- 
nea in  relation  to  the  border  of  the  lower  lid;  the  border  of 
the  upper  lid  is  less  trustworthy,  since  there  may  be  some 
ptosis  or  other  cause  of  inequality  between  the  two  sides. 


EXTERNAL  EXAMINATION  OP  THE  EYE.   5Y 

The  range  of  movement  of  the  eye,  "field  of  fixation,"  or 
"field  of  direct  vision,"  can  be  measured  on  the  perimeter  in 
the  same  way  as  the  ordinary  field  of  "  indirect  vision."  The 
test-object,  e.  y.,a  word  of  small  print,  moved  along  the  various 
meridians  from  the  centre  towards  the  peripher}-,  is  followed  by 
the  eye  under  examination  until  it  can  no  longer  be  read,  i,  e., 
until  the  visual  axis  can  no  longer  be  directed  to  it.  A  coarse 
test-object  would  be  recognized  by  parts  of  the  retina  away  from 
the  yellow  spot,  and  must,  therefore,  not  be  used.  In  this  way 
it  is  found  that  the  normal  range  of  movement  of  the  eye  ex- 
tends through  about  45^  in  each  direction  from  the  centre.  The 
state  of  mobility  of  the  eye,  and  the  progress,  in  cases  of  ocular 
paralysis,  may  be  accurately  recorded  in  this  way.^ 

(11)  Squint  or  strabismus  exists  if  the  visual  axes  are 
not  both  directed  to  the  same  object.  A  squint  may  be  the 
result  either  of  over-action,  or  of  weakness  or  paralysis,  of 
a  muscle.  The  internal  recti,  by  excessive  contraction, 
often  cause  convergent  squint ;  but  most  other  forms  of 
strabismus  result  from  actual  defect  of  nervous  or  muscu- 
lar power. 

When  a  squint  is  well  marked  there  is  no  difiBculty  in 
identifying  the  squinting  eye  as  the  one  which  is  mis- 
directed when  an  object  is  held  up  to  the  patient's  atten- 
tion ;  in  most  cases  the  patient  always  squints  with  the 
same  eye,  but  a  few  persons  can  squint  with  either  indiffer- 
ently, alternating  squint.  Nor  is  there  often  any  doubt  as 
to  whether  the  squint  is  internal,  convergent,  or  external, 
divergent,  i.  e.,  whether  the  axis  of  the  squinting  eye 
crosses  that  of  its  fellow  between  the  patient  and  the  object 
he  looks  at,  or  crosses  it  beyond  this  object,  or  even  posi- 
tively diverges  from  it ;  upward  or  downward  squint, 
though  less  common,  is  almost  as  evident.  But  to  prove 
beyond  doubt  which  is  the  squinting  eye,  direct  the  patient 

1  For  further  details  consult  a  paper  by  Landolt  in  Trans.  luteruat. 
Med.  Congress,  1881,  vol.  iii.  p.  25  (London), 

3* 


58   EXTERNAL  EXAMINATION  OF  THE  EYE. 

to  look  at  a  pencil  held  up  in  the  middle  line  at  about  18'' 
from  his  face,  and  with  a  card  or  piece  of  ground-glass 
cover  the  apparently  sound,  or  "  working"  eye,  the  squint- 
ing e3^e  will  at  once  move  so  as  to  look  at,  or  "fix"  the 
pencil,  proving  that  it  had  previously  been  misdirected.  If 
the  sound  eye  be  watched  behind  the  screen,  it  will  be  seen 
to  squint  as  soon  as  the  affected  eye  "  fixes"  the  object ; 
this  is  known  as  the  secondary  squint,  and  its  direction  is 
the  same  as  that  of  the  original  or  primary  squint.  Thus, 
if  the  primary  squint  be  convergent,  the  secondary  will 
also  be  convergent.  In  squint  from  over-action,  or  from 
mere  disuse,  of  one  muscle,  the  secondary  and  primary 
deviations  are  equal,  but  in  paralytic  squint  the  secondary 
often  exceeds  the  primary.  If  the  squinting  eye  retain  full 
range  of  movement,  i.  e.,  move  in  companionship  with  its 
fellow  in  all  directions,  the  squint  is  termed  concomitant,  in 
contradistinction  to  paralytic;  hence  in  every  case  of  squint 
it  is  necessary  to  test  the  mobility  of  the  eyes.  It  is  also 
important  to  note  whether  the  squint  is  constant  or  only 
occasional  (periodic).^ 

It  was,  until  lately,  usual  to  measure  the  squint  (when 
necessary)  by  means  of  a  scale  placed  on  the  lower  lid  and 
graduated  in  such  a  way  as  to  indicate  in  lines  (or  mm.) 
the  amount  of  deviation.  The  centre  of  this  scale,  marked 
zero,  is  placed  over  the  centre  of  the  lid,  and  therefore  cor- 

1  We  sometimes  meet  with  an  apnare^it  squint,  either  external  or  in- 
ternal. The  optic  axis  of  the  eye  passes  from  a  point  rather  to  the  inner 
side  of  the  y.  s.  through  the  centre  of  the  cornea,  and  forms  a  small 
angle  ("  angle  a")  with  the  visual  axis,  the  line  Avhich  joins  the  y.  s.  to 
the  objectlooked  at  and  which  commonly  cuts  the  cornea  rather  within 
its  centre.  As  we  judge  of  the  apparent  direction  of  a  person's  eyes  by 
the  centres  of  his  corneae,  i.  e.,  by  the  ojJtic  axes,  a  slight  apparent  out- 
ward squint  will  be  produced  if  the  angle,  a,  be,  as  in  many  hyper- 
metropic eyes,  larger  than  usual,  and  an  apparent  convergent  squint  if, 
as  in  myopia,  it  be  smaller.  Apparent  squint  is  always  slight,  and  the 
screen  test  described  in  the  text  gives  a  negative  result. 


EXTERNAL  EXAMINATION  OF  THE  EYE 


59 


responding  to  the  centre  of  the  pupil  if  there  be  no  squint ; 
the  number  which  corresponds  to  the  centre  of  the  pupil  of 
the  squinting  eye  gives  the  linear  measurement  of  the  devi- 
ation. A  more  accurate  and  more  rational  method,  intro- 
duced by  Landolt,  gives  the  deviation  in  terms  of  the 
angle,  d,  Fig.  30,  formed  by  the  visual  axis  of  the  squint- 
ing eye  where  it  cuts  that  of  the  working  eye.  In  Fig.  30, 
L  is  the  squinting  left  eye  of  the  patient  placed  at  the 

Fig.  80. 


Angular  measurement  of  squint.     (After  Landolt.) 

centre  of  a  perimeter  ;  L  x  ,  the  direction  of  its  visual  axis  ; 
L  Ob,  the  direction  its  visual  a.xis  should  have ;  Ob,  an 
object,  as  far  off  as  possible,  at  which  the  patient  is  to  look  ; 
X  a  small  candle-flame  which  the  observer,  stationed  close 
behind  the  perimeter,  moves  along  the  arc  until  he  sees  its 


00   EXTERNAL  EXAMINATION  OF  THE  EYE. 

image  reflected  from  the  centre  of  the  squinting  cornea ; 
the  size  of  the  angle  x  L  Ob,  read  off  on  the  perimeter,  is 
nearly'  the  same  as  that  of  the  angle  of  deviation  d. 

(12)  Diplopia  (double  sight)  is  almost  always  a  result 
of  sciuint,  and  is  usually  most  troublesome  when  the  devi- 
ation is  so  slight  as  to  be  hardly  perceptible.  Diplopia 
caused  by  squint  is,  of  course,  binocular,  and  disappears 
when  one  eye  is  covered.  Uniocular  diplopia  (double 
sight  with  one  eye),  however,  often  occurs  in  commencing 
cataract,  and  sometimes  in  healthy  but  astigmatic  eyes;  it 
has  also  been  met  with  in  some  cases  of  cerebral  tumor. 
In  the  former  cases  it  has  a  physical  cause  in  the  crystal- 
line lens  (sec  Cataract) ;  in  the  latter  it  must  depend  upon 
some  psychical  change. 

To  find  out  what  defect  of  movement  is  causing  binocular 
diplopia,  darken  the  room,  and  ask  the  patient  to  follow 
with  his  eyes  a  lighted  candle,  held  about  6'  from  him, 
moved  successively  into  different  positions,  and  to  describe 
the  relative  places  of  the  double  images  in  each  position. 
Ascertain  which  of  the  two  images  belongs  to  each  eye  by 
placing  before  one  eye  a  strongly-colored  glass,  or  by 
covering  one  eye  and  asking  which  image  disappears.  In 
many  cases  the  image  formed  in  the  squinting  eye  (the 
"  false"  image)  is  less  bright  or  distinct,  and  this  difference 
gives  a  valuable  means  of  distinguishing  the  sound  from 
the  affected  eye  ;  but  the  patient  does  not  always  notice  a 
difference  between  the  two  images,  and  there  may  then  be 
difficulty  in  proving  which  eye  is  at  fault.  The  patient's 
replies  may  be  recorded  on  such  a  diagram  as  Fig.  123  ; 
other  radii  may  of  course  be  added  for  intermediate  posi- 
tions;  the  false  image  is  marked  by  the  dotted  line,  the 
true  one  by  the  unbroken  line.  With  this  graphic  repre- 
sentation of  the  candle  as  it  appears  to  the  patient,  we  can 

1  The  ansrles  X  L  Ob  and  cZ  would  be  exactly  equal  if  Ob  were  far 
eiiuus^li  away  to  make  L  Ob  and  R  Ob  parallel. 


EXTERNAL  EXAMINATION  OF  THE  EYE.   61 

deduce  from  the  apparent  position  of  the  false  image  what 
movements  of  the  corresponding  eye  are  at  fault,  and  con- 
sequently which  muscle  or  muscles  are  defective.  It  is 
essentialthat  the  patient  shouldr\ot  move  his  head  during  the 
examination,  and  that  he  remain  throughout  at  the  same 
distance  from  the  candle.  Remember  that,  in  the  extreme 
lateral  movements,  the  nose  eclipses  one  image.  When  the 
double  images  are  very  wide  apart,  i  e.,  when  there  is  much 
squint,  the  patient  often  fails  to  notice  the  false  image. 

For  the  diagnosis  of  a  case  of  diplopia  it  is  often  suffi- 
cient to  ask  in  which  directions  the  double  sight  is  most 
troublesome,  and  how  the  images  appear  in  respect  to 
height,  lateral  separation,  and  apparent  distance  from  the 
patient.     Chapter  XXI. 

(13)  The  apparent  size  of  an  object  depends,  in  the  first 
place,  on  the  size  of  its  retinal  image,  and  this,  as  already 
shown,  §  19,  p.  38,  depends  upon  {a)  the  size  of  the  visual 
angle,  and  (6)  the  distance  of  the  retina  from  the  nodal 
point.  It  is  clear  that  in  Fig.  20  a  smaller  object  placed 
nearer  to  the  eye  or  a  larger  one  placed  further  off  might 
subtend  the  same  angle  as  Ob,  and  therefore  have  a  retinal 
image  of  the  same  size.  There  are,  however,  other  factors 
contributing  to  our  estimate  of  the  size  of  objects,  especially 
contrast  of  size  and  shade,  estimation  of  distance,  and  effort 
of  accommodation. 

A  white  object  on  a  black  ground  looks  larger  than  a 
black  object  of  the  same  size  on  a  white  ground.  The  fur- 
ther off  an  object  is  judged  to  be,  the  larger  does  it  look. 
The  greater  the  accommodative  effort  used,  whatever  may 
be  the  distance  of  the  object,  the  smaller  does  it  appear  ; 
thus  patients  whose  eyes  are  partly  under  the  influence  of 

1  Apparent  distance  is  also  influenced  by  the  color  of  the  object.  The 
chromatic  aberration  of  the  eye  is  said  to  aflford  the  explanation,  rays 
of  different  refrangibilities  being  focussed  on  slightly  difi'erent  parts  of 
the  retina. 


G2   EXTERNAL  EXAMINATION  OF  THE  EYE. 

atropine,  and  presbyopic  persons  whose  g-lasses  are  too 
weak  conijilain  that  near  objects,  if  looked  at  intently  for 
a  short  time,  become  much  smaller ;  whilst  when  one  eye 
is  under  the  action  of  eserine,  causing  spasm  of  the  accom- 
modation, objects  appear  larger  than  if  held  at  the  same 
distance  from  the  other  eye.  Prisms  with  their  bases 
towards  the  temples  seem  to  diminish  objects  seen  through 
them  by  necessitating  excessive  convergence  of  the  eyes, 
the  converse  of  Fig.  16. 

(14)  Protrusion  (proptosis)  and  enlarg^ement  of  the 
eye. — Unequal  prominence  of  the  two  eyes  is  best  ascer- 
tained by  seating  the  patient  in  a  chair,  standing  behind 
him,  and  comparing  the  summits  of  the  two  corneae  with 
each  other,  and  with  the  bridge  of  the  nose,  or  the  line  of 
the  eyebrows.  The  appearance  of  prominence  or  recession, 
as  seen  from  the  front,  depends  very  much  on  the  quantity 
of  sclerotic  exposed  ;  thus,  slight  ptosis  gives  a  sunken  ap- 
pearance to  the  eyes,  and  in  slight  cases  of  Graves's  disease 
the  proptosis  seems  to  increase  when  the  upper  lids  are 
spasmodically  raised.  It  is  to  be  remembered  that  real 
prominence  of  the  eye  may  depend  on  enlargement  of  the 
eyeball,  myopia,  staphyloma,  or  intra-ocular  tumor,  as  well 
as  on  its  protrusion,  and  that  if  only  one  eye  be  m3'opic, 
the  appearance  will  be  uns3^mmetrical.  Decided  proptosis 
may  follow  tenotomy  or  paralysis  of  one  or  more  ocular 
muscles.  In  hypermetropia,  in  which  the  eyeball  is  too 
short,  and  in  the  rare  cases  of  paralysis  of  the  cervical 
sympathetic,  the  eye  often  looks  sunken. 

(15)  The  uses  of  prisms  have  been  explained  at  p.  35. 
(IG)  Examination  by  focal  illumination  is  described  in 

Chapter  III. 


CHAPTER  III. 

EXAMINATION    OF    THE    EYE    BY    ARTIFICIAL   LIGHT. 

This  includes  (1)  examination  by  focal  or  oblique  light ; 
(2)  examination  by  the  ophthalmoscope. 

1.  Examination  by  Focal  or  Oblique  Light. 

In  using  focal,  oblique,  or  lateral  illumination  the  anterior 
parts  of  the  eye  are  examined  with  the  light  of  a  lamp 
concentrated  by  a  convex  lens.  The  method  is  used  to 
detect  or  examine  opacities  of  the  cornea,  changes  in  the 
appearance  of  the  iris,  alterations  in  the  outline  and  area 
of  the  pupil  from  iritis,  and  opacities  of  the  lens.  Such  an 
examination  is  to  be  made  by  routine  in  every  case  before 
using  the  ophthalmoscope.  We  require  a  somewhat  dark- 
ened room,  a  convex  lens  of  two  or  three  inches  focal 
length,  one  of  the  large  ophthalmoscopic  lenses,  and  a 
bright,  naked  lamp-flame. 

The  patient  is  seated  with  his  face  towards  the  light, 
which  is  about  2'  distance.  The  lens,  held  between  the 
finger  and  thumb,  is  used  like  a  burning-glass,  being  placed 
at  about  its  own  focal  length  from  the  patient's  cornea,  and 
in  the  line  of  the  light,  so  as  to  throw  a  bright  pencil  of 
light  on  the  front  of  the  eye  at  an  angle  with  the  observer's 
line  of  sight.  Thus  all  the  superficial  media  and  structures 
of  the  eye  can  be  successively  examined  under  strong  illu- 
mination, the  distance  of  the  lens  being  varied  a  little 
according  as  its  focus  is  required  to  fall  on  the  cornea,  the 
iris,  or  the  anterior  or  posterior  surface  of  the  crystalline 
lens.     Fig.  31.     By  varying  the  position  of  the  light  and 


64 


EXAMINATION     BY     ARTIFICIAL 


GUT. 


Fig.  31. 


of  tlie  patient's  eye,  making  him  look  up,  down,  and  to 
each  side,  we  can  examine  all  parts  of  the  corneal  surface, 
of  the  iris,  of  the  pupillary  area,  i.  e.,  the  anterior  capsule 
of  the  lens,  and  of  the  lens-substance.  If  the  light  be 
thrown  at  a  very  acute  angle  on  the  cornea  or  lens,  opaci- 
ties are  much  more  visible  than  if  it  fall 
almost  perpendicularly.  By  habitually 
magnifying  the  illuminated  parts  by  a 
second  lens  held  in  the  other  hand,  much 
additional  information  can  be  gained. 

For  complete  exploration  of  all  parts 
of  the  crystalline  lens  the  pupil  must  be 
dilated  with  atropine,  but  careful  exami- 
nation without  atropine  will  generally 
enable  us  to  detect  opacities  lying  in  or 
near  the  axis  of  the  lens  even  if  deeply 
seated.     In  examining  the  posterior  pole 
of  the   lens   the  light 
must  be  thrown  almost 
perpendicularly      into 
the  pupil,  and  the  ob- 
server must  place  his 
eye    as   nearly  in  the 
same    direction    as   is 
possible  without  inter- 
cepting    the    incident 

^      ,  .,,      .    ,.  light.   Opacities  of  the 

Focal  illumination.  ^  ^ 

cornea     and    anterior 

layers  of  the  lens  appear  whitish,  deep  opacities  in  the  lens, 
especially  in  old  people,  look  yellowish,  by  focal  light. 
Tumors,  large  opacities  in  the  vitreous,  and  retinal  detach- 
ments may  be  seen  by  this  method  if  they  lie  close  behind 
the  lens.  Minute  foreign  bodies  in  the  cornea  will  often 
be  seen  by  focal  light  when  invisible,  because  covered  by 
hazy  epithelium,  in  daylight. 


ophthalmoscopic  examination.         g5 

2.  Ophthalmoscopic  Examination. 

The  ophthalmoscope  enables  us  to  see  the  parts  of  the 
eye  behind  the  crystalline  lens,  by  making  the  observer's 
eye  virtually  the  source  of  illumination  for  the  observed 
eye.  Rays  of  light  entering  the  pupil  in  a  given  direction 
are  partly  reflected  back  by  the  choroid  and  retina,  and 
on  emerging  from  the  pupil  take  the  same  or  very  nearly 
the  same  course  that  they  had  on  entering  (§12,  p.  31). 
Hence  the  eye  of  the  observer,  if  so  placed  as  to  receive 
these  returning  rays,  must  also  be  so  placed  as  to  cut  off 
the  entering  rays :  as,  therefore,  no  light  can  enter  in  the 
necessary  direction,  none  can  return  to  the  observer's  eye. 
This  is  why  the  pupil  is  usually  black.  Although  with  a 
large  pupil,  especially  in  a  hypermetropic  or  myopic  eye, 
the  observer  receives  some  of  the  returning  rays,  because 
he  does  not  intercept  all  the  entering  light,  and  in  this  way 
sees  the  pupil  of  a  fiery  red  instead  of  black,  still  for  any 
useful  examination  the  observer's  eye  must,  as  already 
stated,  be  in  the  central  path  of  the  entering,  and  emerging, 
rays.  This  end  is  gained  by  looking  through  a  small  hole 
in  a  mirror,  by  which  light  is  reflected  into  the  patient's 
pupil,  and  this  perforated  mirror  is  the  ophthalmoscope. 
There  are  two  ways  of  seeing  the  deep  parts  of  the  eyeball 
by  this  means. 

A.  The  indirect  method  of  examination,  by  which  a  clear, 
real,  inverted  image  of  the  fundus,  somewhat  magnified,  is 
formed  in  the  air  between  the  patient  and  the  observer. 

The  following  simple  experiment  will  show  how  this  is 
effected :  Take  two  convex  lenses  of  about  '^"  focal  length 
each ;  hold  one  in  the  left  hand,  at  about  ^"  from  this 
print ;  take  the  other  in  the  right  hand,  and,  moving  your 
head  a  few  inches  back,  hold  the  second  lens  at  about  its 
focal  length  in  front  of  the  first ;  you  will  then  see  an  in- 
verted image  of  the  print  slightly  magnified,     a.  Observe 


66 


EXAMINATION     BY    ARTIFICIAL    LIGHT. 


that  in  order  to  see  this  image  clearly  you  have  to  make  aa 
eftbrt,  and  that  you  cannot  see  both  the  image  of  the  print 
and  the  print  itself,  clearly,  at  the  same  moment;  this  is 
because  the  eye  of  the  observer  (obs,  Fig.  82)  cannot  be 
adjusted  for  the  image  (im)  and  the  more  distant  object  (06) 
at  the  same  time.  The  fundus  of  the  eye  seen  on  this  prin- 
ciple is  magnified  about  five  diameters,  if  the  eye  be  normal. 

Fig.  32. 


ob.  The  object,     a.  The  first  lens.     I.  The  second  lens.     iui.  The  mag- 
nified inverted  image  of  ob  viewed  by  the  observer,  oba. 


The  image  is  larger  in  h  and  smaller  in  m.  b.  Notice  that 
if  the  observer's  head  be  moved  slightly  from  side  to  side, 
the  image  will  appear  to  move  in  the  opposite  direction. 

B.  The  direct  method  of  examination,  by  which,  except 
when  the  eye  is  myopic,  a  virtual,  ere3t  image  is  seen, 
more  magnified  than  in  the  former  method  and  situated 
behind  the  patient's  eye. 

The  conditions  are  the  same  as  those  under  which  a  mag- 
nified image  of  any  object  is  seen  through  a  convex  lens, 
Fig.  13,  as  in  the  following  experiment :  Hold  a  convex 
lens  of,  say  3''  focal  length,  at  any  distance  from  this  page 
not  greater  than  3'',  and  place  your  eye  close  to  the  lens. 


OPHTnALMOSCOPIC     EXAMINATION.  67 

The  print  will  be  magnified,  and  seen  in  its  true  position, 
i.  e.,  "  erect."  a.  The  enlargement  will  be  more  the  greater 
the  distance  of  the  lens  from  the  page  up  to  3''  (§§  16  and 
1*7,  p.  34).  If  the  distance  be  further  increased,  the  print 
will  not  be  seen  clearly.  The  image  is  a.  "  virtual"  one, 
because  it  is  the  image  which  would  be  formed  if  the  rays 
which  enter  the  eye  in  a  diverging  direction  could  be  pro- 
longed backwards  until  they  met  behind  the  lens.  Figs.  13 
and  35.  b.  If  the  lens  be  placed  just  at  its  focal  length 
from  the  paper,  the  image  will  be  seen  clearly  only  if  the 
accommodation  be  completely  relaxed,  c.  If  it  be  nearer 
to  the  page,  more  or  less  accommodation  must  be  used,  or 
else  the  observer  must  withdraw  his  head  further  from  the 
lens.  d.  If,  keeping  the  lens  quite  still,  the  observer  with- 
draw his  head,  the  field  of  view  will  be  lessened.  Fig.  14, 
whilst  the  image  will  appear  to  increase  in  size  without 
really  doing  so,  and  these  changes  will  be  greater  the 
nearer  the  lens  is  to  its  focal  distance  from  the  paper  ;  if  it 
be  almost  exactly  at  its  principal  focal  distance,  only  a 
very  small  part  of  the  print  will  be  seen  when  the  head  is 
withdrawn,  e.  If  the  head  be  moved  a  little  from  side  to 
side,  the  image  will  appear  to  move  in  the  same  direction. 
The  emmetropic  eye,  with  the  accommodation  fully  re- 
laxed, is  adjusted  for  distant  objects,  i.  e.,  parallel  rays, 
and  receives  a  clear  image  of  such  objects  on  the  layer  of 
rods  and  cones  of  the  retina,  p.  38.  A  clear  image  of  the 
fundus  of  the  eye,  i.  e.,  the  retina,  optic  disc,  and  choroid, 
can  be  obtained  in  such  an  eye,  as  in  the  experiment  just 
described,  where  the  distance  of  the  lens  from  the  paper 
was  equal  to  or  less  than  its  focal  length,  on  condition  that 
the  eyes,  both  of  patient  and  observer,  be  adjusted  for  in- 
finite distance,  i.  e.,  for  parallel  rays;  in  other  words,  that 
the  accommodation  of  both  be  relaxed.  The  fundus  so 
seen  is  magnified  about  20  diameters. 


08       EXAMINATION     BY     ARTIFICIAL     LIGHT. 

In  order  to  use  the  ophthalmoscope^  it  is  first  necessary 
to  learn  to  manage  the  mirror  and  light.     (1)  Seat  the 
patient  in  a  darkened  room  and  place  a  lamp  with  a  large 
steady,  naked  flame  on  a  level  with  his  eyes,  a  few  inches 
from  his  head,  and  about  in  a  line  with  his  ear.   The  lamp 
may  be  on  either  side,  but  is  usually  placed  on  his  left,  and 
it  is  better  to  keep  to  the  same  side  until  practice  has  given 
steadiness  to  the  various  combined  movements  which  are 
necessary.     (2)  Sit  down  in  front  of  the  patient  with  his 
face  fronting  your  own,  feature  to  feature.   It  is  most  con- 
venient for  the  observer's  face  to  be  a  little  higher  than 
that  of  the  patient.     (3)  Take  the  mirror  of  the  ophthal- 
moscope, without  any  lens  behind,  and  without  the  large 
lens,  in  your  left  hand  for  examining  the  patient's  left  eye, 
and  vice  vei'sd  for  his  right  eye,  hold  it,  mirror  toward  the 
patient,  close  to  your  own  eye,  and  with  the  sight-hole 
placed  so  that,  with  your  other  eye  closed,  you  see  the  pa- 
tient through  it.     Xow  rotate  the  mirror  slightly  toward 
the  lamp  until  the  light  reflected  from  the  flame  is  thrown 
into  the  patient's  pupil,  and  open  your  other  eye.   (4)  You 
will  so  far  have  seen  nothing  except  the  front  of  the  pa- 
tient's eye,  unless  atropine  have  been  used,  for  he  will  have 
looked  at  the  centre  of  the  mirror,  and  his  pupil,  strongly 
contracted,  will  look  either  black  or  very  dull  red.     (5) 
Now  tell  him  to  look  steadily  a  little  to  one  side,  into  va- 
cancy, or  at  an  object  on  the  other  side  of  the  room.    The 
pupil  will  now  become  red — bright  fiery  red  if  it  be  rather 
large,  a  duller  red  if  it  be  small  or  the  patient's  complex- 
ion be  dark.     In  one  position,  when  the  eye  under  exami- 
nation looks  a  little   inward,  the  red    will  change  to  a 
yellowish  or  whitish  color,  and  this  indicates  the  position 
of  the  optic  disc.     (6)  Learn  to  keep  the  light  steadily  on 
the  pupil,  during  slow  movements  backward  and  forward 

1  For  choice  of  instruments  see  Appendix. 


OPHTHALMOSCOPIC    EXAMINATION.  69 

and  from  side  to  side,  taking  care  that  the  patient  keeps 
his  eye  all  the  time  in  the  same  position,  and  does  not  fol- 
low the  movements  of  the  mirror;  the  test  of  steadiness 
will  be  that  the  pupil  remains  of  a  good  red  color  in  all 
positions.  Up  to  this  point  the  examination  may  be  made 
without  atropine  ;  and  so  far  only  a  uniform  red  glare  will 
have  been  seen,  no  details  of  the  fundus  being  visible,  un- 
less the  patient  be  either  myopic  or  considerably  hyperme- 
tropic. 

In  order  to  see  the  details  of  the  fundus  it  is  best  to 
begin  by  learning  the  Indirect  Method,  Fig.  33,  for,  though 
rather  less  easy,  it  is  more  generally  useful  than  the  direct. 

Take  the  mirror  without  any  lens  behind  it  in  one  hand,^ 
and  one  of  the  large  convex  "  objective"  lenses  correspond- 
ing to  /  in  Fig.  32  in  the  other.  Always,  if  possible,  have 
the  pupil  dilated  with  atropine,  for  by  this  means  you  learn 
to  see  the  fundus  much  more  quickly  and  easily.  In  ex- 
amining the  patient's  right  eye  apply  the  mirror  with  your 
right  hand  to  your  right  eye,  holding  the  lens  in  your  left 
hand ;  it  is  best  to  reverse  everything  for  his  left  eye,  but 
the  position  of  the  light  need  not  be  changed.  The  hand 
which  carries  the  lens  should  be  steadied  by  resting  the 
little  or  ring-finger  against  the  patient's  brow  or  temple. 

We  usually  begin  by  looking  for  the  optic  disc,  which  is 
one  of  the  most  important  and  easily  seen  parts.  As  the 
disc  lies  to  the  nasal  side  of  the  posterior  pole  of  the  eye, 
the  cornea  must  be  rotated  a  little  inward,  i.  e.,  the  back  of 
the  eye  outward,  in  order  to  bring  the  disc  opposite  the 
pupil,  when  the  observer  is  immediately  in  front ;  the  right 
eye,  e.  g.,  must  be  directed  to  the  observer's  right  ear,  or  to 
the  uplifted  little  finger  of  his  mirror  hand.     The  patient 

1  But  many  learn  to  see  the  iraasfe  more  quickly  and  easily  by  placing 
a  convex  lens  of  4  D.  behind  the  mirror.  If  the  observer  wears  glasses 
for  reading,  he  should  wear  them,  or  put  a  lens  of  the  same  strength 
behind  the  mirror,  for  the  indirect  examination. 


EXAMINATION     BY    ARTIFICIAL    LIGHT. 


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OPHTHALMOSCOPIC    EXAMINATION,  71 

must  turn  his  eye,  not  bis  head,  in  the  required  direction. 
The  lens  should  be  held  about  'i"-?>",  and  the  observer's 
eye  be  about  15'',  from  the  patient's  eye  ;  the  image  of  the 
fundus  being  formed  in  the  air  2''  or  ?>"  in  front  of  the 
lens,  will  thus  be  situated  about  10''  from  the  observer. 

The  bright-red  glare,  from  the  choroid,  will  be  obvious 
enough  ;  but  most  beginners  find  some  difficulty  in  avoid- 
ing the  reflection  of  the  mirror  from  the  patient's  cornea, 
and  in  adjusting  the  accommodation  and  the  distance  of 
the  head,  so  as  to  see  the  image  clearly.  The  head  must 
be  slowly  moved  a  little  further  from  or  nearer  to  the 
patient,  and  at  the  same  time  an  attempt  made  to  adjust 
the  eyes,  both  being  kept  open,  for  a  point  between  the 
observer  and  the  lens.  As  a  rule,  the  disc  and  retinal  ves- 
sels are  seen  clearly  at  the  first  sitting. 

The  optic  disc — the  ending  of  the  optic  nerve  in  the 
eye  above  the  lamina  cribrosa,  optic  papilla,  Figs.  34  and 
36 — is  round,  well  defined,  much  lighter  in  color  than  the 
fiery  red  of  the  surrounding  fundus,  and  numerous  blood- 
vessels are  seen  to  radiate  from  its  centre,  chiefly  upward 
and  downw^ard.  As  soon  as  the  disc  can  be  easily  seen  the 
student  must  pass  on  to  the  study  of  the  most  important 
details  of  this  part  itself,  and  of  the  other  parts  of  the 
fundus.  Some  of  these  will  l)e  described  here,  and  others 
in  the  chapters  on  the  Diseases  of  the  Choroid  and  Retina, 
and  on  the  Errors  of  Refraction. 

The  disc,  as  a  whole,  is  grayish-pink  in  color  with  an 
admixture  of  yellow.  It  is  nearly  circular,  but  seldom 
perfectly  so,  being  often  apparently  oval  or  slightly  irreg- 
ular. Two  differently  colored  parts  are  noticeable — a  cen- 
tral patch,  whiter  than  the  rest,  and  into  which  most  of 
the  bloodvessels  dip';  and  a  surrounding  part  of  pink  or 
grayish-pink.  In  many  eyes,  especially  in  old  persons,  we 
distinguish  a  third  part,  a  narrow  boundary  line  of  lighter 
color,  which  represents  the  border  of  the  sclerotic,  scleral 


72        EXAMINATION     BY     ARTIFICIAL    LIGHT. 

ring,'^  Fig.  34.  The  bloodvessels  consist  of  several  large 
trunks  and  a  varying  number  of  small  twigs ;  the  large 
trunks  emerge  from  the  central  white  part  of  the  disc,  and 
often  bifurcate  once  or  twice  on  its  area  ;  the  small  twigs 
may  emerge  separately  from  various  parts  of  the  disc,  or 
form  branches  of  the  large  trunks. 

Variations — The  color  of  the  disc  appears  paler  or 
darker  according  to  the  color  of  the  surrounding  choroid, 
the  brightness  of  the  light  used,  and  the  patient's  age  and 
state  of  health.  A  curved  line  of  dark  pigment  often 
bounds  a  part  of  the  circumference  of  the  disc,  Fig.  36, 
and  has  no  pathological  meaning.  The  central  white 
patch  varies  greatly  in  size,  position,  and  distinctness ;  it 
may  be  so  small  as  hardly  to  be  perceptible,  or  very  large  ; 
may  shade  off  gradually  or  be  abruptly  defined ;  may  be 
central  or  eccentric  ;  when  large  it  generally  shows  a  gray- 
ish stippling  or  mottling,  Fig.  36.  This  central  white 
patch  represents  a  hollow,  the  physiological  cup  or  jnt, 
compare  Figs.  36  and  37,  left  by  the  nerve  fibres  as  they 
radiate  out  from  the  centres  of  the  disc  toward  the  retina, 
like  the  tentacles  of  an  open  sea-anemone  ;  and  through  it 
the  chief  bloodvessels  pass  on  their  way  between  the  nerve 
and  the  retina.  This  depression  is  generally  shaped  like  a 
funnel  or  a  dimple,  with  gradually  sloping  sides.  Fig.  37  ; 
but  sometimes  the  sides  are  steep,  or  even  overhanging  ;  in 
other  eyes  it  is  wide,  shallowed,  and  enlarged  toward  the 
outer  side  of  the  discs.  The  physiological  pit  is  whiter 
than  the  rest  of  the  disc,  because  the  grayish-pink  nerve 
fibres  are  absent  at  this  part,  and  we  can,  therefore,  see 
down  to  the  opaque,  white,  fibrous  tissue,  which,  under  the 
name  of  lamina  cribrosa,  forms  the  floor  of  the  whole  disc, 
Fig.  37.     The  stippled  appearance  often  noticed  in  the  pit 

1  I  fail  to  see  the  force  of  the  objection  to  this  term  raised  by  Jaeger 
and  Loring^,  Loring's  Text-book,  i.  p.  57,  since  the  inner  sheath  of  the 
nerve  and  the  fibres  of  the  sclera  are  blended  into  one  at  this  part. 


OPHTHALMOSCOPIC    EXAMINATION 


73 


is  caused  by  the  holes  in  this  lamina,  through  which  the 
bundles  of  ner^e-fibres  pass  on  their  wa}'  to  the  retina  ;  the 
holes  appear  darker  because  filled  by  non-medullated  nerve- 
tibres,  which  reflect  but  little  light. 

The  other  parts  of  the  fandus.-^The  groundwork  is 
of  a  bright  fiery  red — the  choroid,  not  the  retina  ;  in  many 
eyes  this  color  is  nearly  uniform,  but  in  persons  of  very 
light  or  very  dark  complexion  we  see  a  pattern  of  closely- 
set,  tortuous,  red  bands  (vessels  of  the  choroid),  separated 
by  spaces  either  of  darker  or  of  lighter  color,  Fig.  34. 
For  details  see  Chapter  XII. 

Fig.  34. 


Ophthalmoscopic  appearances  of  healthy  fundus  in  a  person  of  ver}' 
fair  complexion.  Scleral  ring  well  marked.  Left  eye,  inverted  image. 
(  Wecker  and  Jaeger. ) 


Upon  this  red  ground  the  vessels  of  the  retina  divide  and 
subdivide  dichotomously.  It  will  be  noticed  that  the  chief 
trunks  pass  almost  vertically  upward  and  downward,  and 
that  no  large  branches  go  to  the  part  apparently  inward 

4 


74       EXAMINATION     BY     ARTIFICIAL     LIGHT. 

from  the  disc  (to  the  left  in  the  figure) ;    that  the  visible 
retinal  vessels  are  comparativeh'  few  and  are  widely  spread ; 
that  they  become  prof;ressively  smaller  as  they  recede  from 
the  optic  disc ;  and  that  they  never  anastomose  with  each 
other.     Special  attention  must  be  given  to  the  part — appar- 
ently to  the  inner,  nasal,  side  of  the  optic  disc,  really  to  its 
outer  temporal  side — which  is  the  region  of  most  accurate 
vision,  the  yellow  spot,  3^  s.,  macula  lidea,  or,  shortly, 
"macula."     In  this  region,  which  comes  into  view  when 
the  patient  looks  straight  at  the  ophthalmoscope,  the  cho- 
roidal  red  is  duller  and  darker  than   elsewhere.      It  is 
skirted  by  large  retinal  vessels  which  give  off  numerous 
twigs  towards  its  centre,  though  none  of  them  can  be  seen 
quite  to  reach  that  point.    Compare  Fig.  78,  Chapter  XIII. 
In  many  eyes  nothing  but  these  indefinite  characters  mark 
the  y.  s.  ;  but  in  some,  especially  in  dark  eyes  and  young 
patients,  a  minute  bright  dot  occupies  its  centre,  and  is 
encircled  by  an  ill-bounded  dark  area,  round  which  again 
a  peculiar  shifting,  white  halo  is  seen.     The  minute  dot  is 
the  fovea  centralis,  the  thinnest  part  of  the  retina.     The 
neighborhood  of  the  disc  and  y.  s.  forms  the  central  region 
of  the  fundus.     The  perijjheral parts  are  explored  by  tell- 
ing the  patient  to  look  successively  up,  down,  and  to  each 
side,  without  moving  his  head.     To  see  the  extreme  peri- 
phery the  observer  must  move  his  head  as  well  as  the 
patient   his   eye.      Toward   the   periphery  the  choroidal 
trunk-vessels  are  often  plainly  visible  even  when  none  were 
distinguishable  at  the  more  central  parts. 

The  vessels  of  the  retina  are  easily  distinguished  from 
those  of  the  choroid  by  their  course  and  mode  of  branching  ; 
by  the  small  size  of  all  except  the  main  trunks  ;  by  their 
sharper  outline  and  clearer  tint ;  but  especially  by  the 
presence  of  a  light  streak  along  the  centre  of  each,  Fig. 
34,  which  gives  them  an  appearance  of  roundness,  very 
different  from  the  flat,  band-like  look  of  the   choroidal  ves- 


OPHTHALMOSCOPIC     EXAMINATION.  75 

sels.  They  are  divisible  into  two  sets — a  darker,  larger, 
somewhat  tortuous  set — the  veins  ;  and  a  lighter,  brighter 
red,  smaller,  and  usually  straighter  set — the  arteries ;  the 
diameter  of  corresponding  branches  being  about  as  3  to  2. 
The  arteries  and  veins  run  pretty  accurately  in  pairs. 
Pressure  on  the  eyeball,  through  the  upper  lid,  causes 
visible  pulsation  of  the  arteries  on  the  disc. 

The  indirect  method  of  examination  is  most  generally 
useful,  because  it  gives  a  larger  field  of  view  under  a  low 
magnifying  power,  about  five  diameters,  and  thus  allows 
us  to  appreciate  the  general  character  and  distribution  of 
any  morbid  changes  better  than  if  we  begin  with  the  direct 
method,  in  which  the  field  of  view  is  smaller  and  the  mag- 
nifying power  much  greater.  It  has  also  the  great  advan- 
tage of  being  equally  applicable  in  all  states  of  refraction  ; 
whereas,  if  the  patient  be  myopic,  his  fundus  cannot  be 
examined  by  the  direct  method  without  the  aid  of  a  suit- 
able concave  lens,  found  experimentally,  placed  behind  the 
mirror,  p.  81.  The  inversion  of  the  image  seen  by  the  in- 
direct method  is  such  that  what  appears  to  be  the  upper  is 
lower,  and  what  appears  to  be  R.  is  L. 

In  the  Direct  MeUiod  the  examination  is  made  by  the 
mirror  alone,  or  with  the  addition  of  a  lens  in  the  clip  or 
disc  behind  it,  but  without  the  intervention  of  the  objec- 
tive lens. 

By  this  method  the  parts,  unless  the  eye«be  myopic,  are 
seen  in  their  true  position.  Fig.  35,  the  upper  part  of  the 
image  corresponding  to  the  upper  part  of  the  fundus,  the 
right  to  the  right,  etc.  ;  it  is,  therefore,  often  called  the 
method  of  the  "erect"  or  "upright"  image,  though,  as 
will  be  seen  below,  these  terms  are  not  strictly  convertible 
with  "direct  examination."  It  is  used:  (1)  to  detect 
opacities  in  the  vitreous  humor  and  detachments  of  the 
retina ;  (2)  to  ascertain  the  condition  of  the  patient's  re- 
fraction, i.  e.,  the  relation  of  his  retina  to  the  focus  of  his 


16        EXAMINATION     BY     ARTIFICIAL     LIGHT. 


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OPHTHAIiMOSCOPIC     EXAMINATION.  7*7 

lens  system  ;  (3)  for  the  minute  examination  of  the  fundus 
by  the  highly-magnified,  virtual,  erect  image  (Fig.  36)  ; 
(4)  for  examining  the  cornea,  iris,  and  lens  with  magnify- 
ing power. 

(1)  To  examine  the  vitreous  humor.  The  patient  is  to 
move  his  eye  freely  in  different  directions,  whilst  the  light 
is  reflected  into  it  from  a  distance  of  a  foot  or  more — for 
details  see  Diseases  of  Vitreous ;  detachments  of  the  retina 
are  seen  in  the  same  way.  Opacities  in  the  vitreous  and 
folds  of  detached  retina,  being  situated  far  within  the  focal 
length  of  the  refractive  media,  are  seen  in  the  erect  posi- 
tion under  the  conditions  mentioned  at  p.  6*7,  c,  the  observer 
being  at  a  considerable  distance  from  the  eye.  If  the  ob- 
server be  close  to  the  patient.  Ace.  must  be  used  or  a  con- 
vex lens  be  placed  behind  the  mirror,  as  in  high  degrees 
of  H.     See  next  page. 

(2)  To  ascertain  the  refraction.  If  when  using  the 
mirror  alone  at  a  distance  of  12''-18'',  or  more,  from  the 
patient's  eye,  we  see  some  of  the  retinal  vessels  clearly  and 
easily,  the  eye  is  either  myopic  or  hypermetropic.  If, 
when  the  observer's  head  is  moved  slightly  from  side  to 
side,  the  vessels  seem  to  move  in  the  same  direction,  the 
image  seen  is  a  virtual  one,  and  the  eye  is  hypermetropic. 
The  eye  is  myopic  if  the  vessels  seem  to  move  in  the  con- 
trary direction  ;  the  image  in  M.  is,  indeed,  formed  and 
seen  in  the  same  way  as  the  inverted  image  seen  by  the 
"indirect"  method  of  examination,  compare  Figs.  33  and 
105,  but  except  in  the  highest  degrees  of  M.  it  is  too  large 
and  too  far  from  the  patient  to  be  useful  for  detailed  exam- 
ination. In  low  degrees  of  M.  this  image  is  formed  so  far 
in  front  of  the  patient's  eye  as  to  be  visible  only  when  the 
observer  is  distant  perhaps  3'  or  4' ;  whilst  in  E.  and  in  the 
lower  degrees  of  H.  the  erect  image  will  not  be  easily  seen 
at  a  greater  distance  than  12''  or  18'',  p.  67,  d,  and  Fig. 
14.     If,  therefore,  in  order  to  get  a  clear  image  by  the 


78        EXAMINATION     BY     ARTIFICIAL     LIGHT. 

direct  method,  the  observer  has  to  go  either  very  near  to, 
or  a  long  way  from,  the  patient,  no  great  error  of  refrac- 
tion can  be  present. 

The  above  tests  only  reveal  qualitatively  the  presence  of 
either  M.  or  H.,  but  by  a  modification  of  the  method,  the 
quantity  of  any  error  of  refraction,  e.  g.,  H.,  can  be  deter- 
mined with  great  accuracy.  {Determination  of  the  refrac- 
tion by  the  ophthalmoscope.)  In  E.,  as  already  stated  at  p. 
67,  the  erect  image  can  be  seen  only  if  the  observer  be 
near  to  the  patient,  and  also  completely  relax  his  accom- 
modation ;  for,  in  experiment  d  there  described,  when  the 
head  was  withdrawn  from  the  lens  the  field  of  view  and 
illumination  rapidly  diminished.  The  same  occurs  with 
the  eye,  but  in  a  much  greater  degree,  and  hence  in  E.  no 
useful  view  can  be  gained  by  the  direct  method  without 
going  very  near  to  the  eye. 

In  H.,  where  the  retina  is  within  the  focus  of  the  lens 
system,  the  erect  image  is  seen  when  close  to  the  patient's 
eye  only  by  an  effort  of  accommodation  in  the  observer, 
just  as  in  the  same  experiment  when  the  lens  was  within 
its  focal  length  from  the  page,  p.  67,  c.  And  as  in  that 
experiment  the  print  was  alse  seen  easily,  even  when  the 
head  was  withdrawn,  so  in  H.  the  erect  image  is  seen  at  a 
distance,  as  well  as  close  to  the  patient. 

If  now  the  observer,  instead  of  increasing  the  convexity 
of  his  crystalline,  place  a  convex  lens  of  equivalent  power 
behind  his  ophthalmoscope  mirror,  this  lens  will  be  a 
measure  of  the  patient's  H,  i.  e.,  it  will  be  the  lens  which, 
when  the  patient's  accommodation  is  in  abeyance,  will  be 
needed  to  bring  parallel  rays  to  a  focus  on  his  retina.  If 
a  higher  lens  be  used,  the  result  will  be  the  same  as  when 
in  the  experiment  the  convex  lens  was  removed  beyond  its 
focal  length  from  the  print ;  the  fundus  will  be  more  or 
less  blurred. 

Hence,  to  measure  H.:    (1)  Ace.  both  in  patient  and 


OPHTHALMOSCOPIC     EXAMINATION.  7  i) 

observ^er  must  be  fully  relaxed,  usually  by  atropine  in  the 
patient  and  by  voluntary  effort  in  the  observer;  (2)  the 
observer  must  go  as  close  as  possible  to  the  patient ;  ( 3)  he 
must  then  place  convex  lenses  behind  his  mirror,  beginning 
at  the  weakest  and  increasing  the  strength,  till  the  highest 
is  reached  which  still  permits  the  details  of  the  o.  d.,  or, 
better,  of  the  y.  s.,  to  be  seen  with  perfect  clearness.  By 
practice  the  distance  between  the  corneae  of  patient  and 
observer  may  be  reduced  to  about  T'.  The  light  must  be 
on  the  same  side  as  the  eye  under  examination.  The  right 
eye  must  examine  the  right,  and  vice  versa. 

In  the  same  way,  though  with  less  accuracy  in  the  high 
degrees,  M.  can  be  measured  by  means  of  concave  lenses ; 
the  lowest  lens  with  which  a  clear  erect  image  is  obtained 
being  slightly  more  than  the  measure  of  the  M. 

It  is  sometimes  useful  to  know  how  much  lengthening  or 
shortening  of  the  eye  corresponds  to  a  given  neutralizing  lens. 
The  following  numbers,  slightly  altered  from  Kuapp,  are  suffi- 
ciently near  the  truth.  The  distance  between  the  eye  of  the 
observer  and  that  of  the  patient  is  supposed  to  be  not  more 
than  1  inch. 

H.  of  1  D.  represents  shortening  of  0.3  mm. 
u  2  " 

3 

u  5  u 

u  g  u 

u  9 

"       12 

18  " 


2 
3 
5 

6 

9 

12 

18 


0.5 

(. 

1 

1.5 

2 

3 

4 

6 

thei 

ling  of  0.3 

0.5 

0.9 

1.3 

1.75 

2.6 

3.5 

5 

80 


EXAMINATION     BY     ARTIFICIAI.    LIGHT. 


Astigmatism  (As.)  may  also  be  measured  by  this  method, 
the  refraction  being  estimated  successively  in  the  two  chief 
meridians  by  means  of  appropriate  retinal  vessels.  See 
Astigmatism.  Any  line,  e.g.,  a  horizontally  running  vessel, 
is  seen  by  means  of  rays  which  pass  through  the  meridian 
of  the  cornea  at  a  right  angle  to  its  course;  hence,  if  a 
vertical  vessel  be  clearly  seen  through  a  -|-  2  D.  lens  there 
is  H.  2  D.  in  the  horizontal  meridian,  etc. 

This  application  of  the  direct  method  needs  much  prac- 
tice. The  lenses,  of  which  there  are  twenty  or  more,  are 
placed  in  a  thin  metal  disc,  which  can  be  revolved  behind 
the  mirror  so  as  to  bring  each  lens  in  succession  opposite 
the  sight-hole.  There  are  many  forms  of  these  "  refraction 
ophthalmoscopes,"  varying  in  the  details  of  their  construc- 
tion.    See  Appendix. 

(3)  The  erect  image  is  very  valuable,  on  account  of  the 
high  magnifying  power,  about  20  diameters  in  the  E.  eye, 

Fig.  36. 


Ophthalmoscopic  appearance  ol  licalthy  disc,  as  seen  in  the  erect 
image.  Dark  vessels,  veins.  Physiological  pit  stippled.  X  1.5  diam- 
eters.    (After  Jaeger.) 


for  the  examination  of  the  finer  details  of  the  fundus. 
The  disc  looks  less  sharply  defined,  because  more  magni- 
fied, than  when  seen  by  the  indirect  method  ;  both  the  disc 


OPHTHALMOSCOPIC    EXAMINATION 


81 


and  the  retina  often  show  a  faint  radiating  striation,  the 
nerve-fibres  ;  the  lamina  cribi^osa  is  often  more  brilliantly 
white  ;  and  the  pigment  epithelium  of  the  choroid  can  be 
recognized  as  a  fine  uniform  dark  stippling. 

If  the  refraction  be  E.  or  H.,  no  lens  is  needed  behind 
the  mirror  ;  if  M.,  a  concave  lens  must  be  placed  in  the 
clip  behind  the  mirror,  of  sufficient  strength  to  give  a  good, 
clear,  erect  image.  The  observer  must  come  as  near  as 
possible  to  the  patient. 

Fig.  37. 


Vertical  section  of  healthy  optic  disc,  etc.  X  about  1.5.  R.  Retina, 
outer  layers  shaded  vertically,  nerve-fibre  layer  shaded  longitudinally. 
Ch,  Choroid.  Scl.  Sclerotic.  L.  Cr,  Lamina  cribrosa.  S.  V.  Sub- 
vaginal  space  between  inner  and  outer  sheath  of  optic  nerve.  The 
central  vein  and  one  of  the  divisions  of  the  central  artery  are  seen  in 
the  nerve  and  disc. 


By  reference  to  Fig.  35  it  will  be  seen  that  only  those 
rays  are  useful  which  strike  near  the  centre  of  the  mirror, 
none  others  entering  the  patient's  pupil ;  hence,  if  the 
aperture  in  the  mirror  be  too  large,  the  fundus  will  not  be 
well  lighted.  It  should  not  be  larger  than  3  mm.,  nor 
smaller  than  2  mm. 

(4)  Minute  changes  in  the  cornea,  iris,  and  lens  can 
often  be  better  studied  by  direct  ophthalmoscopic  examina- 

4* 


82        EXAMINATION     BY     ARTIFICIAL     LIGHT. 

tion  with  a  high  -|-  lens  behind  the  mirror  than  focal  illu- 
mination (p.  64).  All  opacities  seen  in  this  way,  however, 
look  black  against  the  red  background,  whilst  by  focal 
light  they  are  seen  in  their  true  colors. 

Retinoscopy  (Keratoscopy,  Pupilloscopy,  or  the 
Shadow  Test). 

By  this  method  the  refraction  is  determined  by  noticing 
the  direction  of  movement  of  the  light  thrown  on  to  the 
retina  by  the  mirror  when  the  latter  is  rotated.  The  de- 
gree of  error  of  refraction  is  measuredby  the  lens,  which, 
placed  close  to  the  patient's  eye  in  a  case  of  ametropia, 
renders  the  movement  and  other  characters  of  the  illumi- 
nation the  same  as  in  emmetropia. 

The  test  is  most  accurate  when  used  at  a  great  distance 
from  the  patient .  in  practice  a  distance  of  about  1  m. — 
100-120  cm.,  or  3'-4' — is  chosen.  The  observer,  seated  in 
front  of  his  patient,  throws  the  light  from  an  ophthalmo- 
scope mirror  into  the  patient's  pupil.  He  will  then  see  the 
area  of  the  pupil  illuminated,  and  on  slightly  rotating  the 
mirror  will  notice  a  movement  in  this  lighted  area,  which 
movement  will  have  a  direction  either  the  same  as,  or 
opposite  to,  that  in  which  the  mirror  is  turned,  "  with"  or 
"  against  "  the  mirror.  The  lighted  area  is  bordered  by  a 
dark  shadow,  and  it  is  to  the  edge  of  this  shadow  that  the 
attention  must  be  directed.  The  edge  is  parallel  to  the 
axis  on  which  the  mirror  is  turned,  but  moves  in,  and 
shows  the  refraction  of,  the  meridian  at  right  angles  to 
it,  e.  g.,  the  shadow  whose  edge  passes  vertically  across  the 
pupil  moves  across  the  horizontal  meridian,  the  refraction 
of  which  it  indicates,  and  vice  versa.  Retinoscopy  may  be 
practised  with  a  concave  or  a  plane  mirror.  With  the  for- 
mer the  shadow  moves  "  against  "  the  mirror  in  E.  H.  and 
low  M.  ;  and  "  with  "  the  mirror  in  M.  of  more  than   1  D. 


OPHTHALMOSCOPIC     EXAMINATION.  83 

Fig.  38. 


Retinoscopy  (irith  c^7iravf  mirror). 


84       EXAMINATION     BY     ARTIFICIAL    LIGHT. 

With  the  latter  these  movements  are  exactly  reversed. 
The  light  should  be  thrown  as  nearly  as  possible  in  the 
direction  of  the  visual  axis  and  the  lamp  be  placed  imme- 
diately over  the  patient's  head  rather  than  to  one  side, 

(1)  With  a  concave  mirror  (of  about  22  cm,  focus),  Pig. 
38.  In  Fig.  38,  1,  the  mirror,  M,  forms  an  inverted  image, 
I,  of  the  light,  L,  at  its  principal  focus,  and  i  becomes  the 
source  of  light  for  the  eye,  e.  A  second  image  of  i,  again 
inverted,  is  formed  at  i'  on  the  retina  of  e  If  the  far 
point  of  E  be  at  i,  this  retinal  image,  i',  Avill  be  clear  and 
distinct,  but  in  ever}*  other  case  it  will  be  more  or  less  out 
of  focus  and  indistinct.  On  rotating  M  to  m',  i  will  move 
to  i''  andi^  to  i^^  and  these  movements  (of  i  and  i')  will 
occur  no  matter  what  the  refraction  of  E  may  be. 

The  observer  placed  behind  him,  M,  sees  an  image  of  i' 
formed  in  the  same  way  as  the  image  of  the  fundus  seen 
by  the  direct  method,  p.  67,  and  therefore  either  inverted 
and  real,  or  erect  and  virtual,  according  as  the  refraction 
of  the  eye  is  M.  or  H.,  p.  77.  If  the  observer's  eye  be 
accurately  adapted  for  this  image  of  i',  he  will  indeed  see 
not  only  the  light  and  shadow,  but  the  retinal  vessels;  he 
neglects  these,  however,  in  attending  to  the  movements  of 
the  shadow. 

In  the  following  description,  l,  t,  and  i^  are  disregarded, 
i'  or  i'"^  being  considered  as  the  source  of  light. 

If  E  he  myopic,  Fig.  38,  2,  the  image  of  i'  is  real  and  in- 
verted and  formed  at  i'\  the  far  point  of  e,  compare  Fig. 
105.  On  rotating  the  mirror,  as  in  Fig.  38,  1,  i'  will  move 
to  l'^  and  i"  will  move  to  l''^  i.  e.,  the  image  seen  by  the 
observer  moves  in  the  same  dir^ection  as  {or  "  ivitJi^^)  the 
mirror. 

If  E  be  hypermetropic,  Fig.  38,  3,  or  emmetropic,  rays 
reflected  from  its  retina  leave  the  eye  divergent  or  parallel 
and  are  not  brought  to  a  focus  after  emerging;  the  observer 
therefore  sees  a  virtual  image  erect  at  l'',  the  virtual  focus 


OPHTHALMOSCOPTC    EXAMINATION.  85 

of  i',  compare  Fig.  13,  and  see  its  movemeDts  actually  as 
they  occur,  i.  e.,  in  the  same  direction  as  the  movements  of 
the  real  image  i^  or  i'^  and  therefore  "  against''  the  move- 
ments of  the  mirror.  Hence  in  H.  and  Em.  the  shadow 
moves  '' against^^  the  mirror. 

The  above  statement  for  myopia  is  true  only  if  the  ob- 
server be  beyond  the  far  point  of  the  observed  eye.  (See 
Myopia.)  In  M.  of  1  D.  the  rays  returning  from  the  pa- 
tient's eye  are  focussed  at  a  distance  of  1  m.,  and  if  the 
observer  intercept  these  rays  before  they  meet,  Pig.  38,  4, 
he  will  refer  them  toward  i"  and  i"'^  and  obtain  an  erect 
virtual  but  unfocussed  image  of  i',  the  movements  of  which 
will  be  the  same  as  those  in  H.  or  E.,  Fig.  38,  3,  i.  e., 
''  against^^  the  mirror.  Hence,  at  a  distance  of  about  1  m., 
movement  "  against"  the  mirror  may  indicate  M.,  of  about 
1  D.,  or  E.  or  H.  The  lowest  M.  which  can  give  the  char- 
acteristic movement  at  this  distance  is  slightly  more  than 
1  D.,  say  1.25  D. 

(2)  With  a  plane  mirror,  Fig.  39.  Here  the  source  of 
light  for  the  observed  eye  is  an  erect  and  virtual  image  of 
the  flame  formed  at  the  same  distance  behind  the  mirror 
as  the  lamp  is  in  front  of  it.  In  Fig.  39,  1,  this  image  is 
at  I,  the  virtual  focus  of  L.  A  second  and  inverted  image 
of  I  is  formed  on  the  retina  of  e  at  i.  The  movements  of 
these  images,  on  rotation  of  the  mirror,  are  the  reverse  of 
those  of  the  image  i  (and  its  retinal  image  i')  Fig.  38,  1, 
obtained  when  the  concave  mirror  is  used.  When  the 
mirror  m  is  rotated  to  m',  /  will  move  in  the  opposite  direc- 
tion to  V,  bat  its  retinal  image  i  will  move  to  i';  i,  e., 
in  the  same  direction  as,  or  ''with'^  the  mirror.  These 
movements  of  I  and  i  occur  in  every  eye,  whatever  its  re- 
fraction. In  E.  and  H.,  however,  the  movement  of  the 
retinal  image  is  seen  as  it  occurs,  and  therefore  "m//i" 
the  mirror ;  but  in  m.  Fig.  39,  2,  the  observer  sees  an 
inverted  image  of  i  formed  at  the  far  point  of  e,  and  its 


86        EXAMINATION     BY     ARTIFICIAL     LIGHT. 


OPHTHALMOSCOPIC     EXAMINATION.  87 

movements  are  exactly  the  reverse  of  those  of  the  retinal 
image.  Therefore,  when,  on  rotating  m  to  m^,  i  moves  to  i  ^ 
the  image  i'  seen  by  the  observer  moves  to  i'\  i.  e., 
"  against  "  the  mirror.  If  the  plane  mirror  be  used  at  a 
distance  of  rather  more  than  1  m.,  3'-4',  from  the  patient, 
a  movement  of  the  shadow  ''with  "  the  mirror  will  occur  in 
M.  of  1  D.  or  less,  for  the  reasons  given  previously,  Fig. 
38,  4  ;  but  if  the  observer  be  about  2  m.  (say  1')  away,  the 
characteristic  movement  "agamst^^  the  mirror  will  be  ob. 
tained,  unless  the  M.  be  less  than  0.5  D.,  since  the  far  point 
of  an  eye  with  M.  0  5  D.,  and,  therefore,  the  image  seen,  is 
at  2  m.  As  a  plane  mirror  gives  at  a  long  distance  a  better 
illumination  than  a  concave  one,  it  can,  if  necessary,  be 
used  at  a  greater  distance  from  the  patient,  and  by  this 
means  low  degrees  of  ametropia  be  very  accurately  meas- 
ured. Generally,  however,  the  distance  given,  3'-4',  will 
be  found  most  convenient. 

In  employing  retinoscopy  the  patient  is  armed  with  a 
trial  frame,  into  which  lenses  are  successively  put  until  one 
is  reached  which  just  reverses  the  movement  of  the  shadow. 
This  lens  indicates  nearlj^,  but  not  quite,  the  refraction  of 
the  eye  under  observation.  In  H.  we  must  subtract  (about) 
1  D.  from  the  lowest  -\-  lens  which  reverses  the  shadow, 
because  w^e  know  that  this  movement  would  not  occur  until 
a  myopia  of  at  least  1  D.  had  been  produced.  In  M.,  for 
the  same  reason,  1  D.  must  be  added  to  the  lowest  —  lens 
which  reverses  the  shadow. 

Astigmatism  is  easily  detected,  and  its  amount  measured 
by  observing,  on  rotating  the  mirror,  first  from  side  to  side, 
then  from  above  downward,  whether  the  shadow  has  the 
same  movement  and  characters  in  each  direction  ;  or  by 
noting  that  when  the  shadow  in  one  meridian  is  "cor- 
rected" by  a  lens,  the  meridian  at  right  angles  to  it  still 
shows  decided  ametropia.     The  lens  is  then  found  which 


88        EXAMINATION     BY     ARTIFICIAL    LIGHT. 

corrects  the  latter  meridian,  and  the  As.  equals  the  differ- 
ence between  the  two  lenses. 

Apart  from  the  direction  in  which  the  image  (and 
wshadow)  moves,  something  may  be  learned  from  variations 
in  (1)  its  brightness;  (2)  its  rate  of  movement ;  (S)  the 
form,  straight  or  crescentic,  of  its  border.  The  image  is 
brightest,  its  movement  quickest  and  most  extensive,  in 
very  low  M.  and  in  Em.  The  higher  the  ametropia, 
whether  M.  or  H.,  the  duller  the  illumination,  the  slower 
and  less  extensive  its  movement,  and  the  more  crescentic 
and  ill-defined  its  shadow  border.  The  brightness  of  the 
image  depends  on  how  clearly  i,  Fig.  38,  1,  is  focussed  on 
the  retina  ;  the  more  accurately  i'  is  an  image  of  i,  the 
brighter  and  larger  will  i'\  Fig.  38,  2  or  3,  be  ;  and  as  the 
flame  is  rectangular,  the  borders  of  the  image  will  be  nearly 
straight.  These  conditions  occur  when  the  eye  is  exactly 
adapted  for  the  distance  of  i,  i.  e.,  in  M.  of  1  D.  or  less. 
If  the  M.  be  higher  than  1  D.,  i  will  be  out  of  focus,  and, 
therefore,  be  spread  over  a  larger  retinal  area,  and  being 
formed  by  the  same  number  of  rays  as  before,  it  will  be 
less  bright.  The  image  i''.  Fig.  38,  2,  will  be  correspond- 
ingly diffused  and  dull,  and  being  formed  nearer  to  the 
patient's  eye,  as,  for  example,  at  x,  it  will  move  only  from 
X  to  x'  in  the  same  time  as  i^'  takes  in  moving  to  i'^^,  and 
hence  its  movement  is  slower  and  less  extensive.  The  same 
is  true  in  H.,  Fig.  38,  3,  because  the  higher  the  H.,  the 
more  diffused  is  i'  and  the  nearer  is  l'' to  the  patient's  eye. 
In  both  cases,  high  M.  and  high  H.,  the  border  of  the 
shadow  is  crescentic,  because  the  diffused  image  forms  a 
nearly  round  area  on  the  retina. 

Retinoscopy  is  a  valuable  means  of  objectively  deter- 
mining the  quantity  of  any  error  of  refraction,  and  as  it  is 
more  easily  learned,  and,  on  the  whole,  more  accurate  in 
its  results,  than  estimation  by  the  direct  method,  p.  79,  it 


OPHTHALMOSCOPIC    EXAMINATION.  89 

has,  in  the  hands  of  many  of  our  students  and  assistants, 
almost  displaced  the  latter  method  during  the  last  four  or 
five  years  as  a  preliminary  to  testing  the  patient  with  trial 
lenses.  For  the  quick  discovery  of  very  slight  astigmatism, 
and  of  the  direction  of  the  chief  meridians  in  astigmatism 
of  all  degrees,  retinoscopy  probably  excels  all  other 
methods. 

Retinoscopy,  however,  carries  with  it  none  of  the  col- 
lateral advantages  afforded  by  a  thorough  training  in  the 
more  difficult  "direct  method;"  for  in  retinoscopy  w^e  see 
nothing  and  think  nothing  of  the  condition  of  the  fundus 
of  the  eye.  Accurate  retinoscopy  is  not  quicker  than 
measurement  by  the  direct  method ;  indeed,  with  a  good 
instrument,  the  latter  method  certainly  has  the  advantage 
in  rapidity.  I  think  there  is  reason  to  fear  that  the  free 
use  of  retinoscopy  by  students,  before  they  have  mastered 
the  more  difficult  "direct  method,"  may  tend  to  lower  the 
present  high  quality  of  English  ophthalmoscopic  work.  1 
cannot  help  thinking,  therefore,  that  the  importance  of 
retinoscopy  has  been  somewhat  overrated,  and  that  though 
in  some  difficult  cases  it  will  remain  our  best  objective  test, 
we  shall  do  well  generally  to  use  it  as  an  auxiliary  rather 
than  as  a  substitute  for  other  methods. 


PART  II. 

CLINICAL  DIVISION. 


CHAPTER   IV. 

DISEASES   OF   THE    EYELIDS. 

The  border  of  the  lid,  which  contains  the  Meibomian 
glands,  the  follicles  of  the  eyelashes,  and  certain  modified 
sweat-glands  and  sebaceous  glands,  is  often  the  seat  of 
troublesome  disease.  Being  half  skin  and  half  mucous 
membrane,  it  is  moist  and  more  susceptible  than  the  skin 
itself  to  irritation  by  external  causes  ;  being  a  free  border, 
its  circulation  is  terminal,  and  therefore  especially  liable 
to  stagnation.  Its  numerous  and  deeply-reaching  glandu- 
lar structures,  therefore,  furnish  an  apt  seat  for  chronic 
inflammatory  changes. 

Blepharitis  (ophthalmia  tarsi,  tinea  tarsi,  sycosis  tarsi) 
includes  all  cases  in  which  the  border  of  the  eyelid  is  the 
seat  of  subacute  or  chronic  inflammation.  There  are  sev- 
eral types.  The  skin  is  not  much  altered,  but  chronic 
thickening  of  the  conjunctiva  near  the  border  of  the  lid 
is  generally  observed.  The  disease  may  affect  both  lids  or 
only  one,  and  the  whole  length  or  only  a  part. 

In  the  commonest  and  worst  form  the  glands  and  eye- 
lash-follicles are  the  principal  seats  of  the  disease.  The 
symptoms  are,  firm  thickening  and  dusky  congestion  of 
the  border  region,  with  exudation  of  sticky  secretion  from 
its  edge,  glueing  the  lashes  together  into  little  pencils. 


92  DISEASES    OF    THE    EYELIDS. 

Very  mild  cases  present  merely  overgrowth  of  lashes  and 
excess  of  Meibomian  secretion.  But  generally  the  disease 
progresses  ;  little  excoriations,  and  ulcers  covered  by  scab, 
form  along  the  free  border,  and  often  minute  pustules  ap- 
pear;  the  thickening  and  vascularity  increase;  the  lashes 
are  loosened,  and  free  bleeding  occurs  if  they  are  pulled 
out  After  months  or  years  of  varying  activity  some  or 
all  of  the  hair-follicles  become  altered  in  size  and  direction, 
or  quite  obliterated  ;  and  the  lashes  stunted,  misplaced,  or 
entirely  lost.  As  the  thickening  gradually  disappears,  little 
lines,  or  thin  seams,  of  scar  form  just  within  the  edge  of 
the  lid,  and  often  cause  slight  eversion.  The  resulting  ex- 
posure of  the  marginal  conjunctiva,  added  to  the  scanti- 
ness of  the  cilia,  causes  the  disagreeably  raw  and  bald 
appearance  termed  lippitudo;  and  epiphora,  from  eversion, 
tumefaction,  or  narrowing  of  the  puncta,  often  results. 
Often,  however,  the  disease  leads  to  nothing  worse  than  the 
permanent  loss  of  a  certain  number  of  the  lashes. 

In  another  type  the  changes  are  quite  superficial — mar- 
ginal eczema ;  the  patient  is  liable,  perhaps  through  life, 
to  soreness  and  redness  of  the  borders  of  the  lids,  and  little 
crusts,  scales,  or  pustules  form  at  the  roots  of  the  lashes, 
the  growth  of  the  lashes  not  being  much  interfered  with. 
In  such  people  the  eyes  look  weak  or  tender  ;  the  condition 
is  made  worse  by  exposure  to  heat,  dust,  and  wind,  and  by 
long  spells  of  work.  See  Chronic  Lachrymal  Conjunctivitis, 
Chapter  YI. 

Ophthalmia  tarsi  generally  begins  in  childhood,  and  an 
attack  of  measles  is  a  common  exciting  cause.  It  seldom 
becomes  severe  or  persistent  except  from  neglect  of  cleanli- 
ness in  a  child  with  sluggish  circulation  ;  the  patients  are 
generally  anaemic,  often  scrofulous,  and  the  condition  is 
then  often  the  result  of  a  previous  more  acute  ophthalmia. 
In  adults  severe  sycosis  of  the  eyelids  may  accompany 


DISEASES    OF    THE     EYELIDS.  93 

sycosis  of  the  beard,  but,  as  a  rule,  no  tendency  to  such 
disease  of  the  skin  is  observed. 

Treatment. — When  the  inflammatory  symptoms  are 
severe  nothing  has  such  a  marked  effect  as  pulling  out  all 
the  lashes.  Cases  of  a  few  weeks'  standing  may  be  cured 
and  recurrence  in  older  cases  very  much  relieved  by  one 
or  two  such  epilations,  together  with  local  remedies.  Local 
applications  are  always  needed  (1)  for  the  removal  of  the 
scabs,  (2)  to  subdue  the  inflammatory  symptoms.  A  warm 
alkaline  and  tar  lotion,  with  which  the  lids  are  to  be  care- 
fully soaked  for  a  quarter  of  an  hour  night  and  morning, 
followed  by  a  weak  mercurial  ointment  applied  along  the 
edges  of  the  lids  after  each  bathing,  is  an  efficient  plan  if 
the  mother  will  take  the  pains.  In  bad  cases  painting,  or 
pencilling,  the  border  of  the  lid  with  nitrate  of  silver, 
either  in  strong  solution,  or  the  diluted  stick,  or  the  use  of 
weak  copper  drops,  is  very  useful  in  addition  to  the  oint- 
ment. In  old  cases  with  much  epiphora  the  canaliculus 
is  to  be  slit  up.  The  patients  generally  need  a  long  course 
of  iron.     (F.  1,  2,  3,  6;  15,  16;  24,  25,  26.) 

A  stye  is  the  result  of  suppurative  inflammation  of  the 
connective  tissue,  or  of  one  of  the  glands,  in  the  margin  of 
the  lid.  Owing  to  the  close  texture  of  the  tarsus  and  the 
vascularity  of  the  parts,  the  pain  and  swelling  are  often 
severe,  and  even  alarming  to  the  patient.  The  matter  gen- 
erally points  around  an  eyelash ;  but  if  seated  in  a 
Meibomian  gland,  it  may  point  either  to  the  border  of  the 
lid  or  to  the  conjunctiva,  rarely  to  the  skin. 

Styes  almost  always  show  some  derangement  of  health 
especially  of  the  stomach  or  reproductive  organs.  Over- 
use of  the  eyes,  especially  if  ametropic,  is  the  exciting 
cause  in  some  cases ;  exposure  to  cold  wind  in  others.  Styes 
are  very  apt  to  recur,  singly  or  in  crops,  for  several  weeks 
or  months. 


94  DISEASES     OF     THE     EYELIDS. 

Treatment. — A  stye  may  sometimes  be  cut  short  if 
seen  quite  early,  by  the  vigorous  use  of  an  antiphlogistic 
lotion  ;  but  an  incision  followed  by  hot  fomentations  or  a 
poultice  is  usually  more  eflBcacious ;  the  puncture  must  be 
made  parallel  to  the  free  border  and  extend  rather  deeply ; 
a  Beer's  knife  or  broad  needle,  Figs.  160  and  145,  may  be 
used.  The  health  always  needs  attending  to,  and  a  purga- 
tive iron  mixture  often  suits  better  than  anything  else. 

Some  persons  are  subject  to  very  small  postules  or  styes, 
much  more  superficial  than  the  above,  and  less  closely  asso- 
ciated with  derangement  of  health. 

A  Meibomian  gland  is  often  the  scene  of  chronic  over- 
growth, a  little  tumor  in  the  substance  of  the  lid  being  the 
result — Meibomian  cysts,  chalazion.     In  a  few  weeks  or 
months  the  growth  becomes  as  large  as  a  pea,  forming  a 
firm,  hemispherical,  painless  swelling,  over  which  the  skin 
is  freely  movable.    A  dusky  spot  where  the  tarsal  tissues 
are  thinned  marks  the  conjunctival  aspect,  and  when  spon- 
taneous rupture  has  occurred  a  flattened  mass  of  granula- 
tion is  found  there.     The  deeper  part  of  the  gland  is  the 
common  seat  of  disease;  if,  as  sometimes  happens,  the  part 
near  the  edge  of  the  lid  is  affected,  the  tumor  usually 
remains  very  small.    Occasionally  the  growth  pushes  for- 
ward and  adhesion  to  the  skin  occurs;    even  then  it  is 
easily  distinguished  from  a  sebaceous  cyst  by  the  firmness 
of  its  deep  attachment.     During  its  course  the  cyst  may 
inflame  and  even  suppurate,  and  in  the  latter  case  it  forms 
one  variety  of  "stye."      The  same  tumor  may  inflame 
several  times,  and  finally  suppurate  and  shrink.      Like 
styes,  these  tumors  are  apt  to  continue  forming  one  after 
another.     They  are  much  commoner  in  young  adults  than 
earlier  or  later  in  life,  but  they  are  now  and  then  seen  in 
infants.     Patients  as  often  apply  for  the  disfigurement  as 
for  any  discomfort  which  these  little  growths  occasion. 


DISEASES    OF     THE     EYELIDS.  95 

Treatment. — The  cyst  is  to  be  removed  from  the  loiver 
surface  of  the  lid  ;  but  if  it  point  forward  the  iDcision  may 
be  in  the  skin.  The  tumor  generally  consists  of  a  soft, 
pinkish,  gelatinous  mass,  or  of  a  gruelly  or  puriform  fluid, 
without  a  cyst  wall.  Sometimes  the  contents  are  very  firm 
and  adherent.     See  Operations. 

Small  yellow  dots  are  sometimes  seen  on  the  inner  sur- 
face of  the  lids,  due  to  little  cheesy  collections  in  the  Mei- 
bomian glands,  and  causing  irritation  by  their  hardness. 
They  should  be  picked  out  with  the  point  of  a  knife. 

Warty  formations  are  not  very  common  on  the  border 
of  the  lid,  and  are  of  little  consequence,  except  in  elderly 
people,  in  whom  they  should  be  looked  upon  with  suspicion 
as  possible  starting-points  of  rodent  cancer.  A  small 
fleshy,  yellowish-red,  flattened  growth  is  sometimes  met 
w^ith  just  upon  the  tarsal  border,  and  apparently  seated  at 
the  mouth  of  a  Meibomian  gland.  It  causes  some  irrita- 
tion, and  should  be  pared  off.  Small  pellucid  cysts  are 
also  not  uncommon  on  the  lid  border.  Cutaneous  horns 
are  occasionally  seen  on  the  skin  of  the  eyelids. 

Molluscum  contagiosum  is  partly  an  ophthalmic  disease, 
because  so  often  seated  on  the  eyelids.  One  or  more  little 
funded  prominences,  showing  a  small  dimpled  orifice  at 
the  top,  plugged  by  dry  sebaceous  matter,  are  seen  in  the 
skin,  varying  from  the  size  of  a  mustard-seed  to  a  cherry, 
but  usually  not  larger  than  a  sweet  pea ;  at  first  they  are 
hemispherical,  but  afterwards  become  constricted  at  the 
base.  The  skin  is  tightly  stretched,  thinned,  and  adherent. 
The  larger  specimens  sometimes  inflame,  and  their  true 
nature  may  then,  without  due  care,  be  mistaken.  Each 
molluscum  must  be  removed,  the  white,  lobulated,  gland- 
like mass  which  forms  the  growth  being  squeezed  out 
through  the  incision  made  by  a  knife  or  scissors. 

Xanthelasma  palpebrarum  appears  as  one  or  more  yellow 
patches  like  pieces  of  washleather  in  the   ?ikin,   varying 


96  DISEASES    OF    THE     EYELIDS. 

from  mere  dots  to  the  size  of  a  kidney  bean,  quite  soft  in 
texture,  and  very  little  raised.  The  disease  is  commonest 
near  the  inner  canthus,  and,  unless  symmetrical,  is  usually 
on  the  left  side.  It  occurs  chiefly  in  elderly  persons  who 
have  previously  been  subject  to  become  very  dark  around 
the  eyes  when  out  of  health.  The  patches  are  due  to  infil- 
tration of  the  deeper  parts  of  the  skin  by  groups  of  cells 
loaded  with  yellow  fat.  The  frequency  of  xanthelasma 
in  the  eyelids  is  perhaps  related  to  the  normal  presence  of 
certain  peculiar  granular  cells,  some  of  which  contain  pig- 
ment, in  the  skin  of  these  parts. 

The  pediculus  pubis  (crab-louse)  in  very  rare  cases  will 
reach  the  eyelashes  and  flourish  there.  The  lice  cling  close 
to  the  border  of  the  lid,  and  look  like  little  dirty  scabs; 
the  eggs  are  darker,  and  may  also  be  mistaken  for  bits  of 
dirt.  The  absence  of  inflammation  and  the  rather  peculiar 
appearances  will  lead,  in  doubtful  cases,  to  the  use  of  a 
magnifying  glass,  by  which  the  question  will  be  at  once 
settled. 

Ulcers  on  the  eyelids  may  be  malignant,  or  lupous,  or 
syphilitic;  and  in  the  last  case  the  sore  may  be  either  a 
chancre  or  a  tertiary  ulcer. 

Rodent  cancer,  rodent  ulcer,  flat  epithelial  cancer,  is  by  ^ 
far  the  commonest  form  of  carcinoma  affecting  the  eyelids ; 
although  cases  of  eyelid  cancer  occasionally  present  both 
the  clinical  and  pathological  characters  of  ordinary  epithe- 
lioma. The  peculiarities  of  rodent  cancer  are  that  it  is 
very  slow,  that  ulceration  almost  keeps  pace  with  the  new 
growth,  and  that  it  does  not  cause  infection  of  lymphatics. 
It  seldom  begins  before,  generally  not  until  considerably 
after,  middle  life,  and  in  its  course  often  extends  over  many 
years.  Beginning  as  a  "pimple"  or  "wart,"  it  slowly 
spreads,  but  years  may  pass  before  the  ulcer  is  as  large  as 
a  sixpence.  When  first  seen  we  generally  find  a  shallow 
ulcer,  covered  by  a  thin  scab,  most  often  involving  the 


DISEASES    OP    THE    EYELIDS.  97 

skin  at  the  inner  end  of  the  lower  lid.  Its  edge  is  raised, 
sinuous,  nodular,  and  very  hard,  but  neither  inflamed  nor 
tender.  Slowly  extending  both  in  area  and  depth,  it  at- 
tacks all  tissues  alike,  finally  destroying  the  eyeball  and 
opening  into  the  nose.  In  a  few  very  chronic  cases  the 
disease  remains  quite  superficial,  and  cicatrization  may 
occur  at  some  parts  of  the  ulcerated  surface.  Xow  and 
then  a  considerable  nodule  of  growth  forms  in  the  skin 
before  ulceration  begins. 

The  diagnosis  is  generally  easy.  A  long-standing  ulcer 
of  the  eyelids  in  an  adult  is  nearly  certain  to  be  rodent 
cancer.  Tertiary  syphilitic  ulcers  are  much  less  chronic, 
more  inflamed  and  punched  out,  and  devoid  of  the  very 
peculiar,  hard  edge  of  rodent  ulcer;  moreover,  they  are 
very  rare.  Lupus  seldom  occurs  so  late  in  life  as  rodent 
cancer,  presents  more  inflammation  and  much  less  hard- 
ness, and  is  often  accompanied  by  lupus  elsewhere  on  the 
cutaneous  or  mucous  surfaces.  Lupus  is  seldom  difficult 
to  distinguish  on  the  eyelids  from  tertiary  syphilis,  the 
latter  being  more  acute,  more  dusky,  and  showing  more 
loss  of  substance,  with  none  of  the  little,  ill-defined,  soft 
tubercles  seen  in  lupus. 

When  a  chancre  occurs  on  the  eyelid '  the  induration  and 
swelling  are  usually  very  marked,  the  surface  abraded  and 
moist,  but  not  much  ulcerated ;  the  glands  in  front  of  the 
ear  and  behind  the  jaw  become  enlarged.  The  same  glands 
enlarge,  either  with  or  without  suppuration,  in  lupus  and 
in  many  inflammatory  conditions  of  the  lid. 

Several  cases  are  on  record  in  which  a  hard  chancre 
formed  on  the  palpebral  conjunctiva  so  far  from  the  border 
of  the  lid  as  to  be  quite  concealed.  I  have  seen  two  such, 
and  Mr,  James  Adams  and  Mr.  Wherry  have  each  recorded 
one.     In  all  of  these  cases  the  swelling  bore  considerable 

1  An  interesting  monograph  on  this  subject  was  read  by  Dr.  De 
Beck  at  the  American  Ophth.  Soc,  July,  1886. 

5 


98  DISEASES    OF    THE    EYELIDS. 

resemblance  to  a  large  Meibomian  cyst.  In  all  there  were 
enlarged  glands  and  well-marked  constitutional  symptoms. 

Treatment  of  Rodent  Cancer — Early  removal  is  of 
great  importance,  and  probably  the  more  so  in  proportion 
to  the  youth  of  the  patient.  Chloride  of  zinc  paste  or  the 
actual  cautery  is  necessary  in  addition  to  the  knife  in  bad 
cases  ;  scraping  may  also  be  employed.  The  disease  is  very 
apt  to  return  locally.  Even  in  very  advanced  cases,  where 
complete  removal  is  impossible,  the  patient  may  be  made 
much  more  comfortable,  and  life  probably  prolonged,  by 
vigorous  and  repeated  treatment. 

Congenital  ptosis  is  not  a  very  rare  affection.  It  may 
be  double  or  unilateral,  is  present  from  birth,  and  its  causa- 
tion is  unknown.  I  believe  it  is  never  complete.  It  some- 
times seems  to  diminish  in  the  first  few  years  of  life,  but 
probably  never  disappears.  Although  the  lid  droops,  the 
skin  is  often  scanty,  the  lid  being  tight  and  deficient  in  the 
natural  folds.  Operations  have  been  devised  for  producing 
deep  cicatricial  bands,  by  means  of  subcutaneous  sutures 
passed  from  the  brow  to  the  tarsus  (Bowman,  Pagenstecher, 
Wecker).'  These  rather  tedious  procedures  avoid  the  risk 
of  further  shortening  of  the  lid  which  attends  the  simpler 
operation  of  removing  an  elliptical  fold  of  skin.  I  have 
obtained  considerable  improvement  from  Pagenstecher's 
operation.     (See  also  Ocular  Paralysis,  Chapter  XXI.) 

Epicanthus  is  a  rare  condition,  in  which  a  fold  of  skin 
stretches  across  from  the  inner  end  of  the  brow  to  the  side 
of  the  nose,  hiding  the  inner  canthus.  If  it  does  not  dis- 
appear as  the  child's  nose  develops,  an  operation — removal 
of  a  piece  of  skin  from  the  bridge  of  the  nose,  sometimes 
combined  with  canthoplasty — is  indicated. 

1  Panas  has  devised  a  new  operation  more  recently.  Arch.  d'Oph- 
talmologie,  T.  6,  p.  1,  1S86. 


CHAPTER  y. 

DISEASES    OF    THE    LACHRYMAL    APPARATUS. 

These  may  be  divided  into  the  affections  of  the  secret- 
ing parts — the  lachrymal  gland  and  its  ducts ;  and  those 
of  the  drainage  apparatus — the  puncta,  canaliculi,  lachry- 
mal sac,  and  nasal  duct.  In  the  great  majority  of  cases 
the  fault  lies  entirely  in  the  drainage  system. 

The  flow  of  tears  over  the  edge  of  the  lid,  "  watery  eye, "  is 
called  epiphora  or  stillicidium  lacrimarum.  No  useful  pur- 
pose is  served  by  keeping  the  two  names,  and  only  the  former 
will  be  here  used.  Lachrymation  indicates  the  increased 
flow  which  often  accompanies  inflammation  of  the  eyeball. 

The  drainage  system  may  be  at  fault  in  any  part  from 
the  puncta  to  the  lower  end  of  the  nasal  duct. 

The  slightest  change  in  the  position  of  the  lower  punctum 
causes  epiphora.  In  health  the  punctum  is  directed  back- 
ward against  the  eye ;  if  it  look  upward  or  forward,  the 
tears  do  not  all  reach  it,  and  some  will  then  flow  over  a 
lower  part  of  the  lid.  Thus  in  paralysis  of  the  facial  nerve 
the  patient  sometimes  comes  to  us  for  epiphora  before  he 
notices  the  other  symptoms  ;  the  watering  is  caused  partly 
by  loss  of  the  compressing  and  sucking  action  of  the  punctum 
that  is  effected  in  winking,  by  those  fibres  of  the  orbicularis 
which  lie  in  relation  with  the  lachrymal  sac,  partly  by  a 
slight  falling  of  the  lid  away  from  the  eye  and  a  consequent 
displacement  of  the  punctum.  The  various  chronic  dis- 
eases of  the  border  of  the  lids,  ophthalmia  tarsi,  and  also 

^  For  Diseases  of  Lachrymal  Gland,  see  Diseases  of  Orbit.  Chap.  XIX. 


100      DISEASES    OF    LACHRYMAL    APPARATUS. 

granular  disease  of  the  conjunctiva,  granular  lids,  are  com- 
mon sources  of  (1)  tumefaction,  with  narrowing,  of  the 
puncta  and  canaliculi ;  (2)  cicatricial  stricture  of  the  same 
parts  ;  and  in  both  cases  the  puncta  are  displaced  as  well 
as  constricted.  Narrowing,  even  to  complete  obliteration, 
of  the  puncta  is  sometimes  seen  as  the  result  of  former 
inflammation,  of  which  all  traces  have  long  since  passed 
away.  Wounds  by  which  the  canaliculi  are  cut  across 
cause  their  obliteration,  and  epiphora  is  the  result. 

In  all  the  above  cases  epiphora  is  accompanied  by  a  visi- 
ble change  in  the  size  or  position  of  the  punctum,  none  of 
the  signs  of  inflammation  in  the  lachrymal  sac  or  stricture 
in  the  nasal  duct  being  present ;  and  simple  division  of  the 
canaliculus  will  cure,  or  much  relieve,  the  watering.  (See 
Operations.)  This  is,  however,  seldom  necessary  in  the 
epiphora  of  facial  paralysis. 

The  canaliculus  is  occasionally  plugged  by  the  growth  in 
it  of  a  mycelial  fungus,  which,  mingled  with  pus-cells  and 
mucus,  forms  a  yellowish,  or  greenish,  putty-like  concre- 
tion. These  masses  sometimes  calcify,  and  are  then  called 
dacryoliths.^ 

Epiphora  not  explained  by  the  above  causes  is  usually 
due  to  obstruction  in  the  nasal  duct,  and  accompanied  by 
distention  and  disease  of  the  lachrymal  sac  from  the  same 
cause.     Primary  disease  of  the  lachrj^mal  sac  is  rare. 

Obstruction  of  the  nasal  duct  is  usually  caused  by 
chronic  thickening  of  the  mucous  and  submucous  tissues 
lining  the  canal.  Dense,  hard  thickening  causes  a  stric- 
ture, often  very  tight  and  unyielding ;  but  obstruction  is 
often  present,  though  the  canal  be  of  full  size  or  perhaps 
even  dilated,^  excess  of  mucus  being  apparently  the  chief 

1  The  same  term  is  applied  to  concretions,  still  more  rare,  in  the 
ducts  of  the  lachrymal  gland. 

2  There  can  be  little  doubt  that  the  healthy  nasal  duct  varies  much  in 
size  in  different  persons  (Noyes). 


DISEASES    OF     LACHRYMAL    APPARATUS.      101 

cause.  Disease  of  the  duct  occurs  at  all  ages,  and  is  much 
commoner  in  females  than  in  males.^  In  some  cases  the 
change  evidently  forms  a  part  of  a  chronic  disease  of  the 
naso-pharyngeal  mucous  membrane,  but  in  many  no  cause 
can  be  assigned.  Sometimes  stricture  is  the  result  of 
periostitis  or  of  necrosis,  and  of  these  conditions  syphilis, 
either  acquired  or  inherited,  scarlet  fever,  and  smallpox 
are  the  commonest  causes.  Injuries  to  and  growths  in  the 
nose,  or  invading  it,  account  for  a  few  cases. 

A  stricture  may  be  seated  at  any  part  of  the  duct ;  but 
the  upper  end,  where  there  is  often  a  natural  narrowing,  is 
the  commonest  spot. 

Obstruction  of  the  nasal  duct,  by  preventing  the  escape 
of  tears,  leads  to  distention  of  the  lachrymal  sac,  to  chronic 
thickening  of  its  lining  membrane,  and  increased  secretion 
of  mucus.  The  mucus  may  be  clear  or  turbid.  At  length 
a  point  is  reached  at  which  the  distention  can  be  seen  as  a 
little  swelling  under  the  skin  at  the  inner  canthus,  mucocele 
or  chronic  dacryo-cystitis.  This  swelling  can  generally  be 
dispersed  by  pressure  with  the  finger,  the  mucus  and  tears 
either  regurgitating  through  the  canaliculi  or  being  forced 
through  the  duct  into  the  nose.  In  cases  of  old  standing 
the  sac  is  often  much  thickened,  and  may  contain  polypi, 
and  the  swelling  cannot  then  be  entirely  dispersed  by  pres- 
sure. 

A  mucocele  is  always  very  apt  to  inflame  and  suppurate, 
the  result  being  a  lachrymal  abscess.  Most  cases  of  lachry- 
mal abscess,  indeed,  have  been  preceded  by  mucocele.  Its 
formation  gives  rise  to  great  pain,  and  to  tense,  brawny, 
dusky  swelling,  which,  extending  for  a  considerable  dis- 
tance around  the  sac,  is  sometimes  mistaken  for  erysipelas. 
The  matter  always  points  a  little  below  the  tendo-palpe- 
brarum  ;  the  pus  often  burrows  in  front  of  the  sac,  forming 

^  In  a  group  of  113  cousecutive  cases  I  find  89  females  and  ^  males. 


102      DISEASES    OF     LACHRYMAL    APPARATUS. 

little  pouches  in  the  cellular  tissue,  and  if  allowed  to  open 
spontaneously,  a  fistuja,  very  troublesome  to  cure,  is  likely 
to  follow.  If  seen  early,  before  there  is  decided  pointing, 
it  is  best  to  open  the  abscess  by  slitting  the  lower  canaliculus 
freely  into  the  sac,  and  passing  a  knife  down  the  nasal 
duct ;  anaesthesia  is  usually  necessary.  If  interference  be 
delayed,  the  skin  over  the  sac  soon  becomes  thinned,  and 
the  abscess  is  then  best  opened  through  the  skin,  by  a  free 
puncture  inclined  downward  and  a  little  outward  ;  no  an- 
aesthetic is  necessary,  and  the  resulting  scar  is  insignificant. 
When  the  thickening  has  subsided,  under  the  use  of  warm 
lead  lotion  dressing,  the  stricture  of  the  duct  is  to  be  treated ; 
but  the  mucocele  will  form  again,  and  another  abscess  may 
occur  at  any  time,  unless  a  free  passage  can  be  restored 
down  the  nasal  duct. 

Obstinate  chronic  conjunctivitis  is  often  set  up  by  unre- 
lieved lachrymal  obstruction  (Chap.  VI.).  It  has  long  been 
known  that  severe  suppurative  inflammation  was  very 
likely  to  occur  after  any  operation  performed  on  the  cornea 
when  there  was  pus  in  the  lachrymal  sac.  (See  Cataract.) 
These  evidences  of  local  irritation  and  infection  are  now 
believed  often  to  depend  upon  septic  organisms  which, 
owing  to  the  obstruction,  collect  in  the  lachrymal  sac. 

Treatment  of  Mucocele  and  Lachrymal  Stric- 
ture.— The  object  aimed  at  is  the  permanent  dilatation 
of  the  stricture ;  but,  whether  this  can  be  gained  or  not, 
a  free  opening  from  the  canaliculus  into  the  sac  should  be 
maintained,  so  that  the  secretions  may  be  often  and  easily 
squeezed  out. 

Dilatation  by  probing  (Chap.  XXII.)  is  the  ordinary 
and  best  treatment  for  all  strictures,  whether  there  be 
mucocele  or  not,  the  rule  being  to  use  the  largest  probe 
that  will  pass  readily.  The  probing  is  repeated  every  few 
days  or  less  often,  according  to  the  duration  of  its  effect,  and 
often  needs  to  be  continued  for  weeks  or  months.       The 


DISEASES    OF     LACHRYMAL     APPARATUS.       103 

patient  may  sometimes  learn  to  use  the  probe  himself. 
When  the  stricture  is  tough  and  tight,  it  is  best  at  once  to 
divide  it  by  thrusting  a  strong-backed,  narrow  knife  down 
the  duct,  and  afterward  to  use  probes.  In  cases  where  the 
stricture  is  quite  soft,  and  the  obstruction  due  rather  to 
general  thickening  of  the  mucous  membrane  and  over- 
secretion  of  mucus  than  to  dense  fibrous  thickening,  fre- 
quent washing  out  of  the  duct  with  water  or  weak  astrin- 
gents by  means  of  a  lachrymal  syringe  is  quite  as  beneficial 
as,  and  less  painful  than,  probing.  The  diligent  use  of 
astringent  lotions  to  the  conjunctiva  is  also  useful,  particu- 
larly in  soft  strictures,  some  of  the  lotion  reaching  the  sac 
and  duct.  In  cases  of  long  standing,  where  other  treat- 
ment has  failed  and  the  sac  is  much  thickened,  its  complete 
obliteration  by  the  actual  cautery  gives  great  relief;  extir- 
pation of  the  lachrymal  gland  is  also  occasionally  practised. 
For  refractory  children  and  for  patients  who  cannot  be 
seen  often,  a  style  of  silver  or  lead,  passed  in  exactly  the 
same  way  as  a  probe,  but  worn  constantly  for  many  weeks, 
is  very  useful;  but  it  may  slip  into  the  sac  out  of  reach 
unless  furnished  with  a  bend  or  head  so  large  as  to  be 
somewhat  unsightly.  As  a  rule,  probing  should  not  be 
begun  until  the  inflammatory  thickening  and  tenderness 
following  a  lachrymal  abscess  have  subsided.  If  the  probe 
be  used  too  often,  or  with  much  violence,  or  if  false  pas- 
sages be  made,  the  case  may  easily  be  made  worse  instead 
of  better.  It  must  be  confessed,  indeed,  that  in  many 
lachrymal  cases,  whether  the  stricture  be  soft  or  firm, 
treatment,  however  skilful,  gives  only  partial  relief  to  the 
epiphora. 

Suppuration  of  the  lachrymal  sac,  on  one  or  both  sides, 
sometimes  takes  place  in  newborn  infants  without  appa- 
rent cause ;  if  there  be  much  redness,  the  abscess  should 
be  opened,  but  the  suppuration  is  sometimes  chronic,  and 


104       DISEASES     OF     LACHRYMAL     APPARATUS. 

will  cease  under  the  use  of  astringent  lotions.  The  cases 
of  epiphora  with  contracted  punctum,  which  are  sometimes 
met  with  in  older  children,  may  perhaps  be  the  conse- 
quences of  this  infantile  suppuration. 

Cases  in  which  the  sac  or  duct  is  obliterated  by  injury 
can  seldom  be  relieved. 


CHAPTER  YI. 

DISEASES    OF    THE    CONJUNCTIVA. 

It  is  convenient  to  distinguish  those  which,  from  the 
outset,  are  general  and  affect  the  whole  membrane,  ocular 
and  palpebral  alike,  and  of  which  the  various  forms  of  conta- 
gious ophthalmia  are  examples,  from  others  which  primarily 
affect  either  the  ocular  or  the  palpebral  part  alone.  The 
ter^m  "  ophthalmia''''  includes  all  inflammations  of  the  con- 
junctiva, and  should  not  be  applied  to  other  diseases. 

General  Diseases. 

The  conjunctiva,  like  the  urethra,  is  subject  to  purulent 
inflammation,  and,  like  the  respiratory  mucous  membrane, 
is  liable  to  the  muco-purulent  and  to  the  membranous  or 
diphtheritic  forms  of  disease.  All  cases  in  which  there  is 
yellow  discharge  are  in  greater  or  less  degree  contagious. 
The  congestion  which  forms  a  part  of  conjunctivitis  is 
much  influenced  by  age ,  the  younger  the  patient  the  less 
is  the  congestion  in  proportion  to  the  discharge — a  fact  to 
be  borne  in  mind  in  examining  patients  at  both  ends  of 
the  scale. 

Purulent  ophthalmia  (0.  neonatorum,  Gonorrhceal  0., 
Blenorrhoea  of  the  conjunctiva)  is  generally  due  to  con- 
tagion from  the  same  disease,  or  from  an  acute  or  chronic 
discharge  from  the  urethra  or  vagina,  which  may  or  may 
not  be  gonorrhceal.  It  is  commonest  in  newborn  infants 
whose  eyes  have  been  inoculated  from  the  mother  during 
birth  ;  next  in  adults  with  gonorrhoea  ;  it  is  also  seen  some- 
times in  young  girls  who  have  non-venereal  discharges  from 
the  genitals.      Muco-purulent  ophthalmia,  when  quickly 

5* 


106  DISEASES     OP    THE     CONJUNCTIVA. 

passed  on  from  one  to  another,  under  conditions  of  health 
favorable  to  suppuration,  e.  g.,  weakness  after  acute  ex- 
anthenis,  may  be  intensified  into  the  purulent  form.  The 
presence  of  a  special  form  of  micrococcus  in  the  pus-cells 
of  gonorrhoea  and  of  purulent  ophthalmia,  described  by 
Neisser  in  1879,  has  been  confirmed  by  Sattler,  Widmark, 
and  many  others.  The  coccus  is  said  (1)  to  be  absent  in 
some  of  the  milder  forms  of  infantile  ophthalmia  ;  (2) 
when  cultivated,  to  be  capable  of  producing  purulent  oph- 
thalmia by  inoculation  ;  (3)  to  be  usually  present  in  the 
vaginal  discharge  of  women  whose  babies  have  purulent 
ophthalmia.  Gonorrhoea  was  experimentally  produced  by 
inoculation  with  pus  from  purulent  ophthalmia  long  before 
the  days  of  bacterial  pathology.  Like  gonorrhoea,  puru- 
lent ophthalmia  may  occur  more  than  once.  It  varies 
greatly  in  severity,  but  is,  on  the  whole,  much  worse  in 
adults  than  in  infants,  perhaps  because  there  is  much  more 
adenoid  tissue  in  the  conjunctiva  of  adults  than  of  babies 
(Widmark).  The  quality  of  the  infecting  discharge,  no 
doubt,  has  much  influence,  severe  forms  being  generally 
caused  by  inoculation  from  a  recent  or  severe  case ;  but 
chronic  discharge  may  also  give  rise  to  a  severe  attack. 
The  health  of  the  recipient  and  the  previous  condition  of 
the  eyelids  exert  an  important  influence,  and  if  the  lids  be 
granular,  various  slight  causes  sometimes  bring  on  severe 
purulent  ophthalmia. 

The  disease  sets  in  from  twelve  to  about  forty-eight 
hours  after  inoculation  ;  in  infants  the  third  day  after  birth 
is  almost  invariably  given  as  the  date  when  discharge  was 
first  noticed.  Itchiness  and  slight  redness  of  conjunctiva 
soon  pass  on  to  intense  congestion  of  conjunctiva,  with 
chemosis,  tense  inflammatory  swelling  of  the  lids,  great 
pain,  and  discharge.  The  discharge  at  first  is  serous,  or 
like  turbid  whey,  but  soon  becomes  more  profuse,  creamy 
(purulent),  and  yellow,  or  even  slightly  greenish.     Dark, 


GENERAL     DISEASES.  107 

abrupt  ecchymoses  are  often  present.  The  lids,  always 
swollen,  hot,  and  red,  in  bad  cases  become  very  tense  and 
dusky.  The  upper  lid  hangs  down  over  the  lower,  and  is 
often  so  stiff  that  it  cannot  be  completely  everted.  The 
conjunctiva  is  succulent  and  easily  bleeds. 

The  disease  if  untreated  declines  spontaneously,  and  the 
discharge  almost  ceases  in  about  six  weeks,  the  palpebral 
conjunctiva  being  left  thick,  relaxed,  and  more  or  less 
granular.  Cicatricial  changes,  identical  with,  but  less 
severe  than,  those  resulting  from  chronic  granular  lids,  and 
analogous  to  what  occurs  in  stricture  of  the  urethra,  some- 
times follow^ ;  considerable  permanent  thickening  of  the 
ocular  conjunctiva  may  also  occur. 

There  is  a  risk  to  the  cornea  in  this  disease,  partly  from 
strangulation  of  the  vessels,  partly  from  the  local  influence 
of  the  discharge.  If  within  the  first  two  or  three  days  the 
cornea  becomes  hazy  and  dull,  like  that  of  a  dead  fish, 
there  is  great  risk  that  total  or  extensive  sloughing  will 
occur.  In  many  of  the  milder  cases  ulcers  form  a  little 
below  the  centre,  and  rapidly  cause  perforation.  In  other 
cases  clear  deep  ulcers  form  close  to  the  edge  of  the  cornea. 
There  is  less  risk  of  ulceration  of  the  cornea  in  the  purulent 
ophthalmia  of  infants  than  in  that  of  adults,  but  a  form  of 
corneal  affection  appears  in  infants  which  seems  to  be  pecu- 
liar to  them.  This  variety  is  generally  seen  when  the  dis- 
charge is  getting  scanty,  or  perhaps  when  too  much  nitrate 
of  silver  has  been  used;  it  sometimes  occurs  w^hen  the  attack 
is  of  a  diphtheritic  type.  The  cornea  becomes  quickly  and 
almost  entirely  opaque  throughout,  with  the  exception  of  a 
narrow  zone  at  its  edge  ;  the  surface  is  dull,  and  the  epi- 
thelium irregular,  but  there  is  little,  if  any,  loss  of  sub- 
stance. In  many  cases  the  opacity  clears  up  to  a  great 
extent,  even  entirely,  and  eserine  seems  to  help  the  recov- 
ery ;  it  remains  longest  and  densest  at  the  centre.  Either 
one  or  both  eyes  may  be  attacked  ;    in  adults  one  eye  often 


108  DISEASES     OF     THE     CONJUNCTIVA. 

escapes ;    in  infants,  where  the  inoculation  occurs  during 
birth,  both  eyes  almost  always  suffer. 

Treatment. — If  only  one  eye  be  affected,  and  the 
patient  be  old  enough  to  obey  orders,  the  sound  eye  must 
be  covered  up  w4th  the  shield  introduced  by  Dr.  Buller  : 
Take  two  pieces  of  india-rubber  plaster,  one  4J'^,  the  other 
A"  square,  cut  a  round  w  indow  in  the  middle  of  each,  and 
stick  them  together,  with  a  small  watch-glass  inserted  into 
the  window.  The  plaster  is  fixed  by  its  free  border,  and 
by  other  strips,  to  the  nose,  forehead,  and  cheek,  and  the 
patient  looks  through  the  glass;  the  lower  outer  angle  is 
left  open  for  ventilation  ;  particular  attention  is  to  be  paid 
to  the  fastening  on  the  nose.  All  concerned  are  to  be 
warned  as  to  the  risk  of  contagion  and  the  means  of  con- 
veying it.  The  essential  curative  measures  are  :  (1)  Fre- 
quent removal  of  the  discharge  by  the  free  use  of  weak 
antiseptic  or  astringent  lotions  (F.  3,  19,  20,  23,  28,  29). 
Every  hour,  day  and  night,  the  lids  are  gently  opened,  and 
the  discharge  removed  with  soft  bits  of  moistened  rag  or 
cotton-wool ;  or  a  syringe  or  irrigation  apparatus,  such  as 
the  hollow  speculum  or  retractor  described  by  Mr.  Edgar 
Browne  and  Mr  Collins,  may  be  used.^  In  adults,  where 
the  swelling  is  often  extreme  and  very  brawny,  the  cleans- 
ing must  be  done  very  gently  lest  the  congestion  and  irri- 
tability be  increased.  (2)  Iodoform,  at  first  extensively 
tried,  has,  I  believe,  not  given  satisfaction  in  this  disease. 
Many  surgeons  greatly  prefer  weak  nitrate  of  silver  (F.  3) 
to  all  other  remedies.  (3)  Strong  solutions  of  nitrate  of 
silver  or  the  mitigated  solid  nitrate  (F.  1  and  2)  are  of 
great  service  in  shortening  the  attack  and  lessening  the 
risks,  and,  whatever  other  treatment  be  adopted,  they 
should  be  used  in  all  severe  cases,  unless  specially  contra- 
indicated.       A    ten-  or  twenty-grain   solution  is  brushed 

'   British  Medical  Journal,  188.5,  vol.  i. 


GENERAL     DISEASES.  109 

freely  over  the  conjiiiictiva  of  the  lids,  everted  as  well  as 
possible  and  freed  from  discharge.  If  the  mitigated  stick 
is  used,  more  care  is  needed  ;  and  to  prevent  too  great  an 
effect  it  is  to  be  washed  off  with  water,  after  waiting  about 
fifteen  seconds.  These  strong  applications  must  be  made 
by  the  surgeon.  The  pain  caused  by  them  is  lessened,  and 
the  benefit  increased,  by  free  bathing  with  cold  or  iced 
water  afterward.  The  application  is  not  to  be  repeated  until 
the  discharge,  which  will  be  markedly  lessened  lor  some 
hours,  has  begun  to  increase  again;  once  a  day  is  enough 
in  many  cases.  (4)  Between  the  cleansings  either  warm 
or  cold  applications  ;  warmth  is  often  preferred  by  the 
patient.  (5)  In  the  early  stage,  in  adults,  several  leeches 
to  the  temple  will  give  relief,  or,  if  the  swelling  be  very 
tense,  we  may  divide  the  outer  canthus  with  scissors  or 
knife,  and  thus  both  bleed  and  relax  the  parts  at  the  same 
time.  Removal  of  the  ring  of  conjunctiva  which  overlaps 
the  cornea  is  valuable  when  the  chemosis  is  severe.  The 
late  Mr.  Critchett,  in  a  very  bad  case,  divided  the  upper 
lid  vertically  across,  and  kept  its  two  halves  turned  upward 
by  sutures  fastened  to  the  forehead,  at  once  relieving  the 
tension  of  the  lids  and  rendering  the  conjunctiva  acces- 
sible. (6)  The'lids  should  be  often  anointed  with  a  simple 
oiDtraent. 

The  following  additional  precautions  are  important: 
Strong  nitrate  of  silver  applications  are  unsafe  in  the 
earliest  stage,  before  free  discharge  has  set  in,  and  also  in 
cases  where,  even  later  in  the  disease,  there  is  much  hard, 
brawny  swelling  of  the  ocular  conjunctiva  and  compara- 
tively little  discharge  ;  cases,  in  fact,  approaching  the  con- 
dition known  as  diphtheritic  ophthalmia.  In  these  either 
verv  cold  or  very  hot  applications,  leeches,  cleanliness,  and 
weak  lotions  should  be  chiefly  relied  upon.  Ice  and  leeches 
are  seldom  advisable  for  infants.  It  is  of  extreme  import- 
ance to  begin  treatment  very  early,  for  the  cornea  is  often 


110  DISEASES     OF     THE     CONJUNCTIVA. 

irreparably  damaged  within  two  or  three  days.  The 
patients,  if  adults,  are  often  in  feeble  health,  and  need  sup- 
porting treatment.  Ulceration  of  the  cornea  does  not  con- 
tra-indicate  the  use  of  strong  nitrate  of  silver  if  the  discharge 
is  abundant.  Treatment  must  be  continued  so  long  as 
there  is  any  discharge,  for  a  relapse  of  purulent  discharge 
often  takes  place  if  remedies  are  discontinued  too  soon. 
Over-use  of  nitrate  of  silver  sometimes  seems  to  cause  the 
diffuse  opacity  of  the  cornea  referred  to  at  p.  107  ;  I  have 
seen  it  clear  quickly  and  entirely  when  eserine  was  used.  I 
once  saw  hemorrhage  continuing  for  some  time,  without 
apparent  cause,  from  the  conjunctiva  of  the  lid,  in  a  child 
recovering  from  purulent  ophthalmia.  Serious  conjunc- 
tival hemorrhage  has  been  noted  by  Pomeroy  and  Schmidt- 
Rimpler. 

The  systematic  prevention  of  ophthalmia  neonatorumhj 
the  cleansing  and  disinfection  of  the  eyes  of  every  infant 
immediately  after  birth,  sometimes  preceded  by  disinfec- 
tion of  the  maternal  passages,  has  been  introduced  by  Crede 
during  the  last  three  or  four  j^ears,  and  largely  carried  out 
in  many  lying-in  hospitals,  especially  on  the  Continent. 
Crede  applies  a  few  drops  of  a  2  per  cent  solution  of  nitrate 
of  silver  (about  8  gr.  to  ^j)  to  the  conjunctival  sac  once. 
Various  other  agents  or  weaker  solutions  of  silver  have 
been  used.  The  general  result  of  such  measures  has  been 
to  reduce  the  number  of  cases  in  an  astonishing  degree ; 
and  as  it  is  calculated  that  about  a  third  of  all  the  blind 
in  Europe  have  become  so  by  the  ravages  of  this  dis- 
ease, considerable  importance  is  to  be  attached  to  the 
general  adoption  of  Crede's  principle  by  medical  men  and 
midwives.^ 

Muco-purulent  ophthalinia The  commonest  and  best 

characterized  of  the   acute   ophthalmia    is    the    so-called 

1  Particulars  and  statistics  may  be  found  in  "  Edinburgh  Medical 
Journal,"  April,  1888  (Dr.  A.  R.  Simpson),  and  in  more  recent  papers. 


GENERA  li     DISEASES.  Ill 

catarrhal  ophthalmia.  The  name  is  a  bad  one,  for  neither 
does  the  disease  form  part  of  a  general  catarrh  of  the 
respiratory  tract,  nor  does  it  show  the  tendency  to  relapse 
so  characteristic  of  catarrh,  nor  does  it  seem  to  be  caused  by 
cold.  The  disease  attains  its  height  very  quickly,  almost 
always  attacks  both  eyes,  and  gets  well  spontaneously 
in  about  a  fortnight.  There  is  great  congestion,  much 
gritty  pain,  which  often  prevents  sleep,  spasm  of  the  lids, 
free  muco-purulent  discharge,  and,  in  many  cases,  ecchy- 
motic  patches  in  the  conjunctiva.  The  lids  are  somewhat 
swollen  and  red,  but  never  tense,  and  the  cornea  seldom 
suffers. 

This  disease  seems  to  be  much  oftener  communicated 
from  person  to  person  than  purulent  ophthalmia,  for  which 
it  is  sometimes  mistaken.  It  varies  much  in  severity,  even 
in  different  members  of  the  same  household,  who  catch  it 
almost  at  the  same  time,  but  attacks  all  ages  indiscrimi- 
nately. It  is,  I  believe,  commonest  in  warm  weather,  or 
perhaps  at  the  change  from  cold  to  warm.  It  is  rare  to 
find  that  the  patient  has  suffered  from  the  disease  before. 
Any  mild  antiseptic  lotion  Avill  cut  it  short,  nitrate  of  silver 
(F.  3)  being  the  best. 

Troublesome  ophthalmia,  with  muco-purulent  discharge, 
is  common  in  chWdren  after  exanthemata,  especially  measles. 
It  runs  a  less  definite  course  than  the  preceding  disease, 
shows  but  little  tendency  to  spontaneous  cure,  and  is  very 
often  complicated  with  phlyctenular  ulcers  of  the  cornea, 
blepharitis,  and  eruptions  on  the  face  ;  the  patients  are 
frequently  strumous.  The  discharge  is  seldom  so  abundant 
as  in  the  disease  just  considered.  The  treatment  is  often 
troublesome,  and  many  changes  have  to  be  tried ;  weak 
nitrate  of  silver  lotions  (F.  3),  with  the  use  of  the  yellow 
ointment  (F.  12  to  14),  or  boracic  acid  ointment,  both  to 
the  skin  and  conjunctiva,  or  calomel  dusted  into  the  eye, 
are  the  best  local  means ;    atropine  alone  often  increases 


112  DISEASES     OF     THE     CONJUNCTIVA. 

the  irritation.  Careful  attention  to  health  is  necessary. 
The  patients  should  not  be  confined  to  the  house,  but  with 
a  large  shade  over  both  e^^es  should  take  plenty  of  exercise 
in  fine  weather.  The  eyes  should  not  be  bandaged  in  any 
form  of  ophthalmia,  and  ^^oidtices  are  very  seldom  suitable. 

Some  forms  of  acute  conjunctivitis,  with  little  or  no 
discharge,  are  seen  both  in  children  and  adults,  which  do 
not  conform  to  the  above  types,  and  are  of  comparatively 
slight  importance.  Many  such  appear  to  depend  on 
changes  of  weather  or  exposure  to  cold,  and  are  compli- 
cated with  phlyctenulge.  A  few  are  distinctly  rheumatic. 
The  conjunctiva  is  involved  more  or  less  in  herpes  zoster 
of  the  ophthalmic  division  of  the  fifth  nerve,  in  erysipelas 
of  the  face,  in  the  early  stage  of  measles,  and  slightly  in 
eczema  of  the  face.  Slight  degrees  of  chronic  conjunc- 
tivitis are  set  up  by  various  local  irritants,  dust,  smoke, 
cold  wind,  etc.,  and  by  the  strain  attending  the  use  of  the 
eyes  without  glasses  in  cases  of  hypermetropia.  Mention 
must  be  made  of  the  cases  sometimes  seen  in  children, 
where  an  ophthalmia  appears  to  form  part  of  an  impeti- 
ginous or  herpetic  eruption  on  the  face,  with  which  it  is 
simultaneous.  These  again  differ  from  the  commoner  cases 
in  which  the  lids,  cheek,  and  lining  membrane  of  the  nose 
are  irritated  into  an  eruption  by  tears  and  discharge  from 
a  pre-existing  conjunctivitis. 

Muco-purulent  ophthalmia  of  any  kind  becomes  a  very 
important  affair  if  it  breaks  out  in  schools  or  armies,  etc., 
where  granular  disease  of  the  eyelids  is  prevalent. 

Membranous  and  diphtheritic  ophthalmia.  —  In  a  few 
cases  of  ophthalmia,  either  purulent  or  muco-purulent,  the 
discharge  adheres  to  the  conjunctiva  in  the  form  of  a  mem- 
brane, membranous  or  croupous  ojjhthalmia.  Still  more 
rarely,  in  addition  to  membrane  on  the  surface,  the  whole 
depth  of  the  conjunctiva  is  stiffened  by  solid  exudation, 
which  much  impairs  the  mobility  both  of  the  lids  and  eye- 


GENERAL     DISEASES.  113 

balls,  and,  by  compressing  the  vessels,  prevents  the  forma- 
tion of  free  discharge,  and  places  the  nutrition  of  the  cornea 
in  great  peril.  It  is  to  the  latter  cases  that  the  term  diph- 
theritic has  been  limited  by  most  authors  ;  but  we  find 
many  connecting  links  between  the  two  types,  and  between 
each  of  them  and  the  ordinary  purulent  and  muco-purulent 
cases. 

It  is  of  much  consequence  in  practice,  both  for  prognosis 
and  treatment,  to  recognize  the  presence  of  membranous 
discharge  and  of  solid  infiltration  in  any  case  of  ophthal- 
mia ;  for  the  liability  to  severe  corneal  damage  is  much 
increased  l)y  either  of  these  conditions,  especially  by  the 
latter.  The  membrane  may  cover  the  whole  inside  of  the 
lids,  or  it  may  occur  in  separate  or  in  confluent  patches ;  it 
often  begins  at  the  border  of  the  lid,  and  is  seldom  found 
on  the  ocular  conjunctiva.  It  can  be  peeled  off,  the  con- 
junctiva beneath  bleeding  freely  unless  infiltrated  and  solid ; 
in  the  latter  case  the  membrane  is  more  adherent,  the  con- 
junctiva is  of  a  palish  color,  and  scarcely  bleeds  when 
exposed,  and  there  is  little  or  no  purulent  discharge.  In 
most  cases  the  solid  products,  whether  membrane  or  deep 
infiltration,  pass  after  some  days  into  a  stage  of  liquefac- 
tion, with  free  purulent  secretion.  In  rare  cases  the  mem- 
brane forms  and  reforms  for  months.  As  regards  cause: 
(1)  very  rarely  the  process  creeps  up  to  the  conjunctiva 
from  the  nose  in  cases  of  primary  diphtheria,  or  is  caused 
by  inoculation  of  the  conjunctiva  with  membrane;  whilst 
in  a  few  the  ophthalmia  forms  the  first  symptom  of  general 
diphtheria,  or  of  masked  or  anomalous  scarlet  fever.  (2) 
more  commonly  it  is  part  of  a  diphtheritic  type  of  inflam- 
mation following  some  acute  illness  ;  (3)  it  may  be  caused 
by  the  over-use  of  caustics  in  ordinary  purulent  ophthalmia ; 
(4)  it  may  be  due  to  contagion,  either  from  a  similar  case 
or  from  a  purulent  ophthalmia,  or  a  gonorrhoea,  the  diph- 
theritic type  depending  on  some  peculiarity  in  the  health 


114  DISEASES     OP     THE     CONJUNCTIVA. 

or  tissues  of  the  recipient.  Membranous  and  diphtheritic 
ophthalmia  are  seen  most  often  in  children  from  two  to 
eight  years  old,  less  commonly  in  adults  and  infants.  It 
is  commoner  in  North  Germany  than  in  other  parts  of 
Europe,  but  severe  and  even  fatal  cases  are  well  known  in 
our  own  country.  In  two  cases  I  have  seen  the  same  con- 
dition attack  the  skin  of  the  eyelids  and  cause  sloughing 
patches. 

In  treatment  the  cardinal  point  is  not  to  use  nitrate  of 
silver  in  any  form  when  there  are  scanty  discharge  and 
much  solid  infiltration  of  the  conjunctiva.  The  agents  to 
be  relied  on  are  :  (1)  either  ice  or  hot  fomentations  ;  ice,  if 
it  can  be  used  continuously  and  well ;  fomentations,  to  en- 
courage liquid  exudation  and  determination  to  the  skin  if 
the  cold  treatment  cannot  be  carried  out,  or  fails  to  make 
any  impression  on  the  case  ;  (2)  leeches,  if  the  patient's 
state  will  bear  them  ;  (3)  great  cleanliness.  The  presence 
of  membrane  is  no  bar  to  the  use  of  caustics,  provided 
that  the  conjunctiva  is  succulent,  red,  and  bleeds  easily. 
Mr.  Tweedy  strongly  advises  quinine  lotion  used  very  fre- 
quently (F.  27). 

Partial  Diseases. 

Granular  ophthalmia  (trachoma)  is  a  very  important 
malad}^,  characterized  by  slowly  progressive  changes  in  the 
conjunctiva  of  the  eyelids,  in  consequence  of  which  this 
membrane  becomes  thickened,  vascular,  and  roughened  by 
firm  hemispherical  elevations,  instead  of  being  pale,  thin, 
and  smooth.  The  change  usually  begins  in  the  conjunc- 
tiva of  the  lower  lid,  extending  to  the  submucous  tissue  of 
both  lids  at  a  later  period,  and  giving  rise  to  the  growth 
of  much  organized  new  tissue  in  the  deep  parts  of  the 
conjunctiva.  The  tissue  is  afterward  partly  absorbed  and 
partly  converted  into  dense,  tendinous  scar,  which  by  very 


PARTIAL     DISEASES.  115 

close  shrinking  often  gives  rise  to  mnch  trouble.  It  is 
stated  by  Reid  and  others  that  trachoma  follicles  come  to 
the  surface,  open,  discharge  their  contents,  and  leave  minute 
ulcers  ;  but  it  cannot  be  said  clinically  that  trachoma  is  an 
ulcerative  disease,  and  the  prominences  are  not  "  granula- 
tions" in  the  pathological  sense. ^  There  have  been,  and 
still  are,  extraordinary  differences  of  opinion  as  to  the 
origin  and  nature  of  the  "  granulations"  or  ''trachoma 
bodies"  in  this  disease.  The  latest  researches  favor  the 
view  that  they  are  derived  either  from  natural  lymphatic 
follicles  or  from  tubular  glands.  The  question  is  very 
difficult,  whether  from  the  histological  or  the  clinical  point 
of  view,  though  we  may  hope  that  it  will  be  simplified  if 
Sattler's  view  that  trachoma  is  due  to  a  specific  coccus  be 
confirmed,  18S1  and  1882.  Fig.  40  shows  a  section  through 
some  recent  trachoma  bodies. 

Fig.  40. 


X14 

Microscopical  section  through  four  recent  trachoma  bodies  ("  sago- 
grain  granulations") ,  from  the  lower  lid  of  a  young  Irish  soldier  whose 
eyes  became  affected  in  the  late  Egyptian  campaigns.  The  epithelial 
cells  became  almost  indistinguishable  from  those  of  the  growth  where 
they  cover  the  largest  nodule.  No  reticulum  can  be  made  out  between 
the  cells  of  which  the  growths  are  composed. 

The  disease  is  first  shown  by  the  presence,  on  the  lower 
lid,  of  a  number  of  rounded,  pale,  semitransparent  bodies 
like  little  grains  of  boiled  sago,  or  sometimes  looking  like 
vesicles;  the  so-called  "vesicular,"  or  "sago-grain,"  or 
"follicular"  granulations,  Fig.  41.      Judging  clinically, 

^  I  am  aware  that  Raehlmann  makes  a  contrary  statement. 


lie  DISEASES    OF    THE     CONJUNCTIVA. 

they  are,  to  a  certain  degree,  normal,  and  are  seen,  espe- 
cially on  the  lower  lids,  in  many  young  persons  with  slight 
ophthalmia,  who  never  afterwards  suffer  from  true  granu- 
lar lids.  Such  mild  cases,  in  which  no  parts  deeper  than 
the  normal  lymphatic  follicles  and  papillae  are  affected, 
and    in    which    recovery   takes   place   without    cicatricial 

Fig.  41. 


Granular  lower  lid.     (After  Eble.) 

changes,  are  by  Saemisch  and  some  other  authors  placed, 
under  the  name  of  conjunctivitis  follicular  is,  in  a  separate 
category  from  the  granular  disease ;  the  two  conditions 
being  supposed  due  to  radically  different  causes.  But  the 
frequent  coincidence  of  transitional  forms  in  the  same  case, 
the  fact  that  both  "  follicular  conjunctivitis-'  and  well- 
marked  granular  disease  admittedly  occur  under  the  same 
general  conditions,  and  that  in  a  given  case  the  distinctions 
between  "  follicles"  and  "  granulations'' often  cannot  be 
made  until  it  is  known  whether  or  no  cicatricial  changes 
will  occur,  certainly  much  lessen  the  clinical  value  of  the 
asserted  pathological  difference. 

Granular  disease  is  very  important  because  it  greatly 
increases  the  susceptibility  of  the  conjunctiva  to  take  on 
acute  inflammation  and  to  produce  contagious  discharge; 
makes  it  less  amenable  to  treatment,  and  very  liable  to 
relapses  of  ophthalmia  for  many  years;  and  often  gives 
rise  to  deformities  of  the  lid  and  to  serious  damage  of  the 
cornea.  In  crowded  poor-law  schools  we  see  many  cases 
of  granular  lids  in  which  there  is  no  history  of  an  acute 


PARTIAL    DISEASES.  117 

attack  having  ever  occurred,  but  in  ordinary  practice  it  is 
rare  to  see  such. 

Chronic  granular  disease  is  the  result  (I)  of  prolonged 
overcrowding,  or  rather  of  long  residence  in  badlv-venti- 
lated  and  damp  rooms;  it  used  to  be  very  abundant  in  the 
army  and  navy,  and  is  still  seen  in  great  perfection  in 
workhouse  schools ;  (2)  a  generally  low  state  of  health, 
no  doubt,  increases  the  susceptibility  to  it ;  (3)  it  is,  cseteris 
paribus,  commonest  and  most  quickly  produced  in  children ; 
(4)  certain  races  are  peculiarly  liable  to  suffer,  e.  g.,  the 
Irish,  the  Jews,  and  some  other  Eastern  races,  and  some  of 
the  German  and  French  races.  The  Irish  and  Jews  carry 
it  with  them  all  over  the  world,  and  transmit  the  liability 
to  their  descendants  wherever  they  live.  Negroes  in  Amer- 
ica are  said  to  be  almost  exempt;  (5)  damp  and  low-lying 
climates  are  more  productive  of  it  than  others  ;  thus  it  is 
rare  in  Switzerland.  Possibly  w^hat  are  now  race  tenden- 
cies may  be  the  expression  of  climatal  conditions  acting 
on  the  same  race  through  many  generations.  It  is  difficult 
clinically  to  decide  whether  the  trachoma  growths,  apart 
from  the  discharge,  are  caused  by  contagion,  or  by  the  in- 
fluence of  non-vital  causes,  such  as  damp  and  impure  air ; 
many  high  authorities  held  for  a  long  time  that  the  chronic 
disease  was  contagious,  and  even  communicable  at  a  dis- 
tance through  the  air,  without  the  presence  of  any  appre- 
ciable discharge.  When  accompanied  by  discharge,  the 
disease  is  contagious  :  and  it  is  generally  held  that  the  dis- 
charge from  a  case  of  trachoma  is  specific,  i.  e.,  that  it  will 
give  rise  by  contagion,  not  only  to  muco-purulent  or  puru- 
lent ophthalmia,  but  to  the  true  granular  disease. 

Sattler  in  1881-2  believed  that  he  had  discovered  a  spe- 
cific microbe  for  trachoma  ;  bis  results  have  been  substan- 
tially confirmed  by  Michel  and  others,  and  it  is  held  by 
Koch  and  other  recent  investigators  that  in  mixed  cases  ot 
catarrhal  and  granular  disease  two  specific  microbes  exist. 


118  DISEASES    OF    THE    CONJUNCTIVA. 

Should  this  prove  true,  it  will  at  once  simplify  and  explain 
the  varying  characters  of  contagious  ophthalmia  compli- 
cated by  granular  lids. 

Those  who  practise  in  the  army,  or  who  have  charge  of 
such  institutions  as  pauper  schools,  will  find  that  in  prac- 
tice the  causes  of  the  chronic  granular  condition  are  in- 
extricably mixed  up  with  all  kinds  of  facilities  for  con- 
tagion, and  that  it  will  be  necessary  to  fight  against  two 
enemies — the  cause  of  spontaneous  chronic  granular  dis- 
ease, and  the  sources  of  contagious  discharge.  The  former 
is  to  be  combated  by  improved  hygienic  conditions,  espe- 
cially by  free  ventilation,  dry  air,  abundant  open-air  exer- 
cise, and  improvement  of  the  general  vigor.  The  sources 
of  contagion  are  endless,  especially  since,  as  has  been 
stated,  granular  patients  are  liable  to  relapses  of  muco- 
purulent discharge  from  almost  any  slight  irritation.  Fre- 
quent inspection  of  all  the  eyes,  rigid  separation  of  all  who 
show  any  discharge  or  are  known  as  especially  subject  to 
relapses,  arrangements  for  washing  such  as  will  prevent  the 
use  of  towels  and  water  in  common,  extreme  care  against 
the  introduction  of  contagious  cases  from  without — such 
are  the  chief  preventive  measures.  Extra  precautions  will 
be  needed  in  time  of  war  or  famine,  or  when  measles  or 
scarlet  fever  is  prevalent,  or  during  marches  through  hot, 
sandy,  or  windy  districts. 

The  curative  treatment,  when  discharge  is  present,  does 
not  differ  from  that  of  the  acute  ophthalmiae  already  given. 
The  use  of  strong  astringents  (solid  sulphate  of  copper)  or 
caustics  (nitrate  of  silver  in  strong  solution,  or  in  the  miti- 
gated solid  pencil),  however,  is  generally  needed  in  order 
to  make  much  impression  on  the  granular  state  of  the 
lids.  The  lids  being  thoroughly  everted,  are  touched  all 
over  with  one  or  other  application,  and  this  is  repeated 
daily,  or  less  often  ;  some  experience  being  required  before 
we  can  decide  how  often  to  touch  the  evelids  in  each  case. 


PARTIAL     DISEASES.  119 

B}"  careful  treatment  on  this  principle  most  patients  may 
be  kept  comfortably  free  from  active  symptoms,  many 
relapses  may  be  prevented,  the  duration  of  the  disease 
shortened,  and  the  risks  of  secondary  damage  to  the  cornea 
much  lessened.  Do  what  we  will,  however,  granular  dis- 
ease when  well  established  is  most  tedious,  and  fastens 
many  risks  and  disabilities  on  its  subjects  for  5^ears  to 
come. 

For  routine  treatment  on  a  large  scale  nothing  is  so 
effectual  as  nitrate  of  silver,  either  a  ten-  or  twenty-grain 
solution  or  the  mitigated  solid  point  (F.  1  and  2).  But 
silver  has  the  disadvantage  of  sometimes  permanently 
staining  the  conjunctiva  after  long  use,  and  in  very  chronic 
cases  I  think  either  sulphate  of  copper  or  the  lapus  divi- 
nus  (F.  5)  is  to  be  preferred,  especially  as  the  patient  may 
sometimes  be  taught  to  evert  his  own  lids  and  use  it  him- 
self. The  solid  mitigated  nitrate  of  silver  needs  washing 
off  with  w^ater  at  first,  but  in  old  cases  it  is  often  better  not 
to  do  so. 

Results  of  granular  disease Friction  by  the  granula- 
tions of  the  upper  lid,  a,  Fig.  42,  especially  in  cases  of  long 
standing  where  some  scarring  is  present,  6,  often  causes 

Fig.  42. 


a'' 

Granular  upper  lid.     a.    Granulations,     h.    Line  of  scar  in  t3'pical 
position,  parallel  with  border  of  lid. 

cloudiness  of  the  cornea,  partly  from  ulceration,  but  mainly 
from  the  growth  of  a  layer  of  new  and  very  vascular  tis- 


120  DISEASES    OP    THE    CONJUNCTIVA. 

sue,  in  the  superficial  layers  of  the  cornea — pannus,^  Fig. 
43.  In  later  periods  the  conjunctiva  and  deeper  tissues 
are  shortened  and  puckered  by  the  scar  following  absorp- 
tion of  the  "granulations,"  Fig.  42,  b.  These  changes, 
when  severe,  often  lead  to  inversion  of  the  border  of  the  lid, 
entropion  ;  when  slighter,  some  or  all  of  the  lashes  may  be 
distorted  so  as  to  rub  against  the  cornea,  without  actually 
turning  inward,  ^is^zc/iiasis,^?'zc/iiasis;  and  these  conditions 

Fig.  43. 


Section  showing  layer  of  new  and  vascular  tissue  (pannus)  between 
epithelium  {Ept.)  and  cornea  ( C) .  *SW.  Sclerotic.  C.  J/.  Ciliary  mus- 
cle.    Sch.  C.  Schlemm's  canal.     /.  Iris.     X  about  10  diameters. 

are  often  combined  with  pannus.  Pan nus  begins  beneath 
the  upper  lid,  its  vessels  are  superficial  and  continuous 
with  those  of  the  conjunctiva,  and  are  distributed  in  rela- 
tion to  the  parts  covered  by  the  lid,  not  in  reference  to  the 
structure  of  the  cornea.  Fig.  44.  The  proper  corneal  tis- 
sue suffers  but  little  except  where  ulcers  occur  ;  but  when 
the  vascularity  is  extreme  it  may  soften  and  bulge,  even 
without  ulcerating. 

1  It  is  doubtful  how  far  the  development  of  pannus  is  due  to  friction, 
or  to  extension  of  the  trachoma  over  the  sclerotic  to  the  cornea.  Tra- 
choma bodies  may  certainly  be  sometimes  seen  on  the  ocular  conjunc- 
tiva. Raehlmann  states  that  the  first  sign  of  pannus  consists  in  a  col- 
lection of  lymph-cells  in  the  cornea  beneath  Bowman's  membrane  ; 
subsequently  a  layer  resembling  adenoid  tissue  is  found  there  containing 
blood  and  lymphatic  vessels.  That  friction  may  alter  the  epithelium  is 
proved  by  certain  cases  in  which  the  upper  half  of  the  cornea  loses  its 
polish  during  a  temporary  papillary  roughening  of  the  upper  lid. 


PARTIAL    DISEASES.  121 

Pannus  disappears  when  the  granular  lid  or  the  displace- 
ment of  lashes  is  cured.  Yery  severe  and  universal  pannus 
is  sometimes  best  treated  by  artificial  inoculation  with  puru- 
lent ophthalmia,  the  inflammation  being-  followed  by  oblit- 
eration of  vessels  and  clearing  of  the  cornea  ;   but  this 

Fig.  44. 


Pannus  affecting  upper  half  of  cornea. 

treatment  needs  great  judgment  and  caution.  More  re- 
cently an  infusion  of  the  seeds  known  in  commerce  as 
"jequirity"  (F.  40)  has  been  introduced  into  Europe  by 
de  Wecker.  It  acts  in  much  the  same  way  as  pus  from 
purulent  ophthalmia,  but  less  severely  ;  a  very  acute  attack 
of  diphtheritic  or  purulent  ophthalmia  with  much  swelling 
comes  on  a  few  hours  after  the  infusion  has  been  used,  lasts 
a  few  days,  and  is  followed  by  more  or  less  shrinking  of 
the  trachoma  bodies  and  of  the  vessels.  It  occasionally 
causes  glandular  swellings  in  the  neck  and  considerable 
general  disturbance.  Repeated  attacks  may  be  induced 
with  safety  at  intervals  of  a  few  weeks.  Jequirity  proba- 
bly depends  for  its  action  upon  a  non-organized  ferment 
such  as  is  found  in  some  other  seeds.  Sattler  believed, 
from  experiment,  that  a  specific  bacillus  was  the  active 
agent,  1883,  but  his  results  have  been  negatived  by  Wid- 
mark,  Klein,  and  several  others  ;  whilst  an  albuminous  ex- 
tract free  from  organisms,  but  possessing  the  peculiar  prop- 

6 


122  DISEASES    OF    THE    CONJUNCTIVA. 

erties  of  the  infusion  of  the  seed,  has  been  separated  by 
Warden  and  Waddell,  Salomonsen,  and  others.^  Much  dif- 
ference of  opinion  exists  as  to  the  clinical  value  of  jequirity, 
owing  to  its  having  been  often  employed  too  strong  and  in 
unsuitable  cases;  it  is  not  safe  unless  there  are  vessels  on 
the  cornea,  and,  safety  apart,  it  is  of  little  or  no  use  if  the 
conjunctiva  be  succulent  and  producing  pus.  It  should  be 
reserved  for  old,  dry,  granular  lids  with  more  or  less  pan- 
nus,  and  in  such  I  have  repeatedly  had  excellent  results 
from  it.  Removal  of  a  zone  of  conjunctiva  and  subcon- 
junctival tissue,  syndectomy ,peritomy ,  from  around  the  cor- 
nea is  free  from  risk  and  sometimes  very  beneficial  in  old 
eases  which,  though  severe,  are  not  bad  enough  for  inocu- 
lation. In  old  cases  of  granular  disease,  even  where  no 
complications  have  arisen,  the  upper  lids  often  droop  from 
relaxation  of  the  loose  conjunctiva  above  the  tarsal  carti- 
lage, and  the  patient  acquires  a  sleepy  look. 

For  the  cure  of  the  displaced  lashes  and  incurved  eye- 
lids we  may:  (1)  repeatedly  pull  out  the  lashes  with  for- 
ceps ;  (2)  extirpate  all  the  lashes  by  cutting  out  a  narrow 
strip  of  the  marginal  tissues  of  the  lid ;  (3)  attempt  by 
operation  to  restore  the  lashes  to  their  proper  direction, 
Chap.  XXII.  ;  (4)  employ  electrolysis  ;  for  a  few^  lashes  I 
now  use  sewing  needles,  inserting  several  at  a  time  into  the 
hair  follicles,  and  passing  the  current  through  all  at  once, 
by  means  of  a  broad  eyelid  forceps ;  such  operations  well 
selected  and  carefully  performed  give  very  good  results  ; 
but  as  the  inner  surface  of  the  lid  continues  to  shorten, 
and  this  shortening  tends  to  reproduce  the  original  state  of 
things,  some  of  these  procedures  give  only  temporary  relief. 

Chronic  conjunctivitis,  chiefly  of  the  lower  lid,  is  a 
common  disease,  especially  in  elderly  people.     There  is 

1  Mr.  Martindale  last  year  went  to  considerable  trouble  in  trying  to 
prepare  such  an  active  principle  for  me,  but  unfortunately  the  substance 
he  separated  was  almost  inert. 


PARTIAL    DISEASES.  123 

more  or  less  soreness  and  smarting,  redness  and  papillary 
roughness  of  the  inner  surface  of  the  lid  or  of  both  lids, 
but  very  little  discharge  and  no  trachoma  granulations. 
The  caruncle  is  red  and  fleshy,  as  it  is  in  all  forms  of  pal- 
pebral conjunctivitis,  and  there  is  often  soreness  of  the  lids 
at  the  canthi.  Lapis  di  vinus  is  one  of  the  best  applications, 
and  yellow  ointment  is  sometimes  useful  (F.  5  and  12.) 

Lachrymal  conjunctivitis. — Troublesome  chronic  con- 
junctivitis, often  complicated  by  small  pustules  at  the  roots 
of  the  lashes,  or  by  chronic  blepharitis,  is  a  common  result  of 
lachrymal  obstruction.  Recently  microorganisms  of  several 
kinds  associated  with  pus-formation  have  been  found  in 
these  little  abscesses  as  well  as  in  pus  from  the  lachrymal 
sac  (Widmark).  Palpebral  conjunctivitis  of  long  standing 
with  watering,  gummy  discharge,  and  more  or  less  blephar- 
itis, should,  especially  if  confined  to  one  eye,  always  lead 
to  the  suspicion  of  mucocele  or  chronic  lachrymal  abscess. 

The  rare  disease  described  as  Amyloid  of  the  Conjunctiva 
seems  scarcely  to  have  been  noticed  in  this  country.  De- 
tailed accounts  of  its  clinical  and  pathological  characters 
may  be  found  in  Knapp's  Archives  of  Ophthalmology,  vols. 
X.  and  xi.,  and  an  excellent  abstract  of  one  of  these  papers 
appeared  in  the  Ophthalmic  Review  for  August,  1882. 

Spring  catarrh. — A  peculiar  and  apparently  specific 
chronic  disease,  affecting  the  conjunctiva  of  the  globe  and 
upper  lid.  In  the  former  situation  it  takes  the  form  of 
confluent  broad  patches  of  fleshy-looking  thickening  of  a 
light  brown-pink  color,  slightly  overlapping  the  edge  of 
the  cornea  for  a  considerable  part  of  its  circumference. 
In  the  latter  situation  it  occurs  as  large,  pale,  flat-topped 
granulations,  which  are  sometimes  made  to  assume  poly- 
gonal outlines  by  their  pressure  upon  one  another.  They 
begin,  like  trachoma,  at  the  inner  and  outer  end  of  the  lid  : 
either  variety  may  occur  separately.  The  disease  is  worst 
in  the  warm  part  of  the  year,  but  it  lasts  in  some  cases 


124  DISEASES    OF    THE     CONJUNCTIVA. 

many  years,  and  gives  but  little  ti'ouble  ;  the  growths  on 
the  upper  lid  do  not  produce  pannus.  The  thickening  is 
said  to  consist  chiefly  of  epithelium,  and  not  to  affect  the 
deep  tissues. 

Treatment  by  nitrate  of  silver  is  unnecessary  ;  occasional 
touching  of  the  larger  granulations  by  the  galvano-cautery 
is  the  best  treatment.  Unlike  trachoma,  it  occurs  com- 
monly in  all  classes  of  society,  and  is  probably  not  con- 
tagious ;  hence  its  differential  diagnosis  in  children  at  school 
is  very  important.  Hitherto  it  has  not  been  noticed  much 
in  this  country,  but  probably  it  is  not  so  rare  as  has  been 
thought. 

Conjunctivitis  from  drugs. — The  local  use  of  atropine 
sometimes  gives  rise  to  a  peculiar  inflammation  of  the  con- 
junctiva and  skin  of  the  lid — atropine  irritation.  The 
conjunctiva  of  the  lids  becomes  vascular,  thickened,  and 
even  granular,  and  usually  the  skin  is  reddened,  slightly 
excoriated,  and  somewhat  shining.  This  effect  of  atropine 
is  commonest  in  old  people.  Some  persons  are  very  sus- 
ceptible, and  cannot  bear  even  a  drop  or  two  without  suf- 
fering in  some  degree.  Daturine  and  duboisin  cause  less 
irritation  and  may  be  used  instead  ;  but  it  is  better,  if  pos- 
.sible,  not  to  use  mydriatics  at  all  for  a  few  days.  An 
ointment  containing  lead  and  zinc  should  be  applied  to 
the  lids,  and  zinc  or  silver  lotion  to  the  conjunctiva  ;  some- 
times glycerine  suits  better  than  ointment.  In  susceptible 
persons  I  have  not  found  this  peculiar  inflammation  pre- 
vented, either  by  the  use  of  solutions  made  with  antiseptics, 
or  of  solutions  quite  freshly  made.  Eserine  sometimes 
causes  identical  symptoms.  Congestion  of  the  conjunctiva 
has  been  seen  among  those  employed  in  aniline  dye-works ; 
conjunctivitis  was  seen  by  Trousseau  in  4  to  5  per  cent,  of 
patients  treated  for  psoriasis  by  chrysophanic  acid.  If  con- 
tinued long  enough,  arsenic  will  in  some  persons  produce 


PARTIAL    DISEASES.  125 

redness  and  congestion  of  the  conjunctiva.  The  action  of 
jequiritj  is  described  on  p.  121. 

Primary  shrinking  of  the  conjunctiva  (Pemphigus  of 
Conjunctiva). — A  very  peculiar  and  rather  rare  disease,  in 
which,  with  the  phenomena  of  chronic  inflammation,  the 
whole  conjunctiva  slowly  atrophies  and  contracts,  owing  to 
the  formation  in  it  of  cicatricial  tissue.  During  the  earlier 
stages,  the  thickening  of  the  tarsus  and  the  congestion,  with 
scarring  of  the  palpheral  conjunctiva,  have  sometimes  led 
to  the  disease  being  mistaken  for  trachoma  ;  the  two  mala- 
dies are,  however,  quite  distinct.  Finally,  the  whole  con- 
junctival sac  disappears,  and  the  free  borders  of  the  lids, 
fixed  closely  to  the  globe,  are  directly  continuous  with  the 
cornea,  which  ,  irritated  and  dried  by  exposure  and  want 
of  secretion,  becomes  opaque  and  covered  with  crusts — 
"xerosis."     No  treatment  seems  of  any  use. 

In  some  of  the  cases  there  has  been  a  history  of  general 
pemphigus,  and  reason  to  believe  that  the  disease  of  the 
conjunctiva  resulted  from  a  modified  form  of  pemphigus 
eruption. 


CHAPTER  YII. 

DISEASES   OF    THE    CORNEA. 

A    Ulcers  and  Non-specific  Inflammatory 
Diseases. 

Inflammation  of  the  cornea  may  be  circumscribed  or 
diffuse,  and,  though  usually  affecting  the  proper  corneal 
tissue,  may  be  limited  to  the  epithelium  on  either  of  its 
surfaces.  It  may  be  a  local  process  leading  to  formation 
of  pus  or  to  ulceration  ;  or  the  expression  of  a  constitu- 
tional disease,  such  as  inherited  syphilis  ;  or  it  may  form 
part,  and  perhaps  only  a  minor  part,  of  disease  involving 
also  the  deeper  parts  of  the  eyeball — the  iris  (kerato-iritis) 
or  sclerotic  (sclero-keratitis),  for  example. 

The  different  varieties  of  corneal  ulceration  and  suppu- 
rative inflammation  form  a  very  large  and  important  con- 
tingent of  ophthalmic  cases.  The  cornea,  although  a 
fibrous  structure,  is  further  removed  from  the  bloodvessels 
than  almost  any  other  tissue,  and  its  delicate  surface  is 
much  exposed;  it  is,  therefore,  extremely  susceptible  both 
to  external  irritants  and  to  disturbances  of  nutrition  from 
defective  supply,  or  bad  quality,  of  blood ;  ulceration  of 
the  cornea  always  means  deficient  vitality.  Lastly,  its  sur- 
face is  so  delicate,  and  its  perfect  transparency  and  regu- 
larity so  important,  that  slight  injuries  and  irritations  are 
of  more  moment  here  than  in  any  other  part  of  the  body. 

When  inflamed,  the  cornea  always  loses  its  transparency. 
If  only  the  anterior  epithelium  be  involved,  the  surface 
loses  its  polish,  and  looks  like  clear  glass  which  has  been 
breathed   upon — "steamy,"  or  finely  pitted^-a  condition 


NON-SPECIFIC     INFLAMMATORY    DISEASES.       127 

occurring-  in  many  states  of  disease.  Thickening  of  the 
epithelium,  and,  still  more,  exudation  into  the  corneal 
tissue,  is  shown  by  a  white,  grayish,  or  yellowish  tint.  If 
the  corneal  tissue  be  opalescent,  while  the  surface  is  at  the 
same  time  "steamy,  "the  term  "ground-glass"  gives  a  good 
idea  of  the  appearance,  though,  to  make  the  simile  correct, 
the  glass  ought  to  be  milky  throughout,  as  well  as  ground 
on  the  surface.  Rapid  suppurative  inflammation  is  preceded 
by  a  stage  of  diffused  opalescence  ;  hence  rapid  opalescence 
is  a  sign  of  imminent  danger  in  such  diseases  as  purulent 
ophthalmia,  severe  burns,  or  paralysis  of  the  fifth  nerve. 
Fluorescence  of  the  cornea  has  been  seen  as  the  result  of 
the  use  of  quinine  lotions  to  the  eye,  and  appears  to  be  due 
to  the  deposit  of  crystals  of  quinine  in  the  cornea. 

Before  describing  the  most  important  types  of  corneal 
ulcer,  it  is  convenient  to  mention  the  principal  changes  at- 
tendant on  ulceration  of  the  cornea  in  general.  An  ulcer 
of  the  cornea  is  preceded  by  a  stage  of  infiltration,  and  the 
inflamed  spot  is  generally  a  little  raised.  After  the  centre 
of  the  spot  has  broken  down  into  an  ulcer,  the  extent, 
density,  and  color  of  the  infiltration  at  its  base  and  edges 
are  important  guides  to  its  future  course.  The  ulcer,  when 
healed,  leaves  a  hazy  or  opaque  spot,  leucoma  if  dense, 
nebula  if  faint,  which  is  slight,  and  may  disappear  entirely 
if  superficial,  but  will  in  part  be  permanent  if  the  ulcer 
have  been  deep.  These  opacities  are  likely  to  clear,  cseteris 
paribus,  in  proportion  to  the  youth  of  the  patient;  time, 
also,  is  a  very  important  element,  nebulae  often  continuing 
to  clear  slowly  for  years ;  local  stimulation  aids  in  the  re- 
moval of  the  opacities,  one  of  the  best  applications  being 
the  ointment  of  yellow  oxide  of  mercury  (F.  12,  13). 
Other  modes  of  local  stimulation  have  been  recommended, 
such  as  tattooing,  massage,  electrolysis,  and  the  use  of 
various  powders.  Several  successful  attempts  have  been 
made  to  transplant  circular  portions  of  the  clear  cornea 


128  DISEASES     OF     THE     CORNEA 

removed  from  the  rabbit  by  a  trephine,  to  replace  portions 
of  the  hnman  cornea  rendered  opaque  by  disease.  To  do 
this  successfully  it  is  necessary  to  leave  behind  Descemet's 
membrane  in  the  diseased  cornea  (v.  Hippel).  Ulcers 
which  have  little  or  no  infiltration  often  heal  slowly,  but 
leave  a  permanent  facet  or  flattening;  such  facets  destroy 
the  regular  curvature  of  the  cornea,  and  thus  often  cause 
more  damage  to  vision  than  a  considerable  degree  of  mere 
clouding.  During  repair  bloodvessels  often  form  and  pass 
from  the  nearest  part  of  the  corneal  edge  to  the  ulcer,  to 
disappear  when  healing  is  complete ;  phlyctenular  ulcers, 
however,  are  vascular  from  the  beginning.  Corneal  im- 
perfections are,  of  course,  most  damaging  to  vision  when 
placed  over  the  pupil. 

The  chief  sywjjtoms  of  corneal  ulceration  are  :  (l)p/?o- 
tophobia,  with  its  consequence,  spasm  of  the  orbicularis, 
blepharospasm ;  (2)  congestion ;  (3)  pain.  All  three  symp- 
toms vary  extremely  in  degree  in  different  cases.  As  a 
broad  rule  with  many  exceptions,  we  may  say  that  toler- 
ance of  light  is  worse  in  children  than  in  adults,  worse 
with  superficial  than  with  deep  ulcers,  and  worse  in  persons 
who  are  strumous  and  irritable  than  in  those  with  healthy 
tissues  and  good  tone.  Photophobia  should  always  lead  to 
a  careful  inspection  of  the  cornea,  and  we  shall  then  some- 
times be  surprised  to  find  how  slight  a  change  gives  rise  to 
this  symptom  in  its  severest  form.  The  degree  of  conges- 
tion varies  with  the  seat  and  cause  of  the  ulcer,  and  with 
the  patient's  age,  being  usually  greatest  in  adults.  The 
visible  congestion  is,  as  in  iritis,  due  especially  to  disten- 
tion of  the  subconjunctival  twigs  of  the  ciliary  zone,  Fig. 
25,  Ant.  Cil.,  and  Fig.  28,  bat  there  is  often  congestion  of 
the  conjunctival  vessels  as  well.  In  some  forms  of  mar- 
ginal ulcer,  only  those  vessels  which  feed  the  diseased  part 
are  congested.  Great  pain  in  and  around  the  eye  often  at- 
tends the  earlier  stages  of  corneal  abscess,  and  is  common 


NON-SPECIFIC     INFLAMMATORY     DISEASES.       129 

in  Diany  acute  ulcers  ;  as  a  symptom,  it,  of  course,  always 
needs  careful  attention  ;  it  is  generally  relieved  by  those 
local  measures  which  are  best  for  the  disease  itself. 


Types  of  Corneal    Ulceration. 

(1)  One  of  the  simplest  forms  is  the  small  ceritral  ulcer 
often  seen  in  young  children.  A  little  grayish-white  spot 
forms  in  the  central  part  of  the  cornea,  at  first  elevated 
and  bluntly  conical,  afterward  showing  a  minute  shallow 
crater  ;  the  congestion  and  photophobia  vary,  but  are  often 
slight.  The  ulcer  is  usually  single,  but  it  is  apt  to  recur  in 
the  same  or  the  other  eye.  The  infiltration  often  extends 
into  the  corneal  tissue,  and  the  residual  opacity  remains  for 
a  long  time,  if  not  permanently.  The  patients  are  always 
•badly  nourished.  In  most  cases  the  ulcer  Cjuickly  heals, 
but  now  and  then  the  infiltration  passes  into  an  abscess,  or 
a  spreading,  suppurating  ulcer. 

(2)  Less  commonly  we  meet  with  a  central  ulcer,  or  a 
succession  of  ulcers,  of  a  much  more  chronic  character,  and 
attended  with  little  or  no  infiltration.  After  lasting  for 
months  the  loss  of  tissue  is  only  partly  repaired,  and  a 
shallow  depression  or  a  flat  facet  is  left  with  but  little  loss 
of  transparency.  Some  of  the  best  examples  are  seen  in 
anaemic  or  strumous  patients  with  granular  lids  of  long 
standing. 

(3)  Phlyctenular  ophthalmia  andphlycienular  ulcers  of 
cornea  (phlyctenulae,  herpes  corneje,  pustular  ophthalmia, 
marginal  keratitis,  "  strumous  ophthalmia  "). — The  forma- 
tion of  little  papules,  or  pustules,  on  or  near  the  corneal 
margin  is  exceedingly  common,  either  independently  or  as 
a  complication  of  some  existing  ophthalmia.  Although 
there  are  many  varieties  and  degrees  of  phlyctenular  in- 
flammation in  respect  to  the  seat,  extent,  and  course  of  the 
disease,  the  following  features  are  common  to  all :     They 

6* 


130  disp:ases   of   the   cornea. 

show  a  strong  tendency  to  recur  during  several  years  ;  they 
are  seldom  seen  in  very  young  children,  and  comparatively 
seldom  after  middle  life ;  they  occur  so  often  in  strumous 
subjects,  that  we  are  justified  in  suspecting  scrofulous  ten- 
dencies in  all  who  suffer  much  from  them  ;  ophthalmia 
tarsi  is  often  seen  in  the  same  patients ;  the  first  attack 
often  follows  closely  after  an  acute  exanthem,  and  especi- 
ally after  measles ;  the  cases  are  much  influenced  by  climate 
and  weather,  and  their  condition  often  varies  extremely 
from  day  to  day  without  making  either  progress  or  re- 
gress. 

An  elevated  spot,  like  a  papule,  commonly  about  the 
size  of  a  small  mustard-seed,  is  seen  either  on  the  white  of 
the  eye  near  the  cornea,  or  upon,  or  just  within,  the  corneal 
border.  It  is  preceded  and  accompanied  by  localized  con- 
gestion. Its  top  sometimes  becomes  as  yellow  as  that  of 
an  acne  pustule,  but  more  often  when  seen  it  has  become 
abraded  and  aphthous-looking.  Pustules  at  a  little  dis- 
tance from  the  cornea,  Fig.  45,  although  generally  larger 
than  those  seated  on  the  corneal  border,  occasion  less  pho- 
tophobia and  are  more  easily  cured.  Pustules  at  the  cor- 
neal border,  though  often  very  small,  cause  troublesome, 
and  even  very  severe,  photophobia ;  they  are  troublesome 
in  proportion  rather  to  their  number  than  their  size,  and 
if  so  numerous  as  to  form  a  ring  around  the  cornea,  their 
cure  is  often  very  tedious. 

A  pustule  is  always  liable,  even  when  it  has  begun  on 
the  conjunctiva,  to  advance  as  a  superficial  ulcer  on  to  the 
cornea,  though  it  never  extends  in  the  opposite  direction 
over  the  sclerotic.  Such  a  phlyctenular  ulcer,  if  it  do  not 
stop  near  the  corneal  border,  will  make,  in  an  almost  radial 
direction,  for  the  centre,  carrying  with  it  a  leash  of  vessels 
which  lie  upon  the  track  of  opacity  left  in  the  wake  of  the 
ulcer.  Fig.  46.  Finally,  the  ulceration  stops,  the  vessels 
dwindle  and  disappear,  but  the  path  of  opacity  seldom 


NON-SPEGIFIO     INFLAMMATORY     DISEASES.       131 


clears  up  entirely.  The  term  recurrent  vascular  ulcer  is 
used  when  such  ulcers  are  solitary  ;  but  they  are  often 
multiple  as  well  as  recurrent,  and  then,  in  the  end,  we  find 
the  cornea  covered  by  a  thin,  irregular  network  of  super- 
ficial vessels  on  a  patchy,  uneven,  hazy  surface,  the  so- 
called  "phlyctenular  pannus.''^ 


Fig.  45. 


Fig    46. 


^^ 


Phlyctenular  ophthalmia,  conjunc- 
tival form.     (Dabymple.) 


Phlyctenular  ulcer.     (Travers.) 


A  common  variety  of  phlyctenular  inflammation,  aptly 
called  marginal  conjunctivitis,  perhaps  allied  to  the  "spring 
catarrh''^  of  Continental  authors,  occurs  in  the  form  of  a 
slight,  granular-looking,  often  vascular,  swelling,  begin- 
ning crescentially  above  or  below,  but  often  extending  all 
around  the  edge  of  the  cornea.  If  the  process  continue, 
the  cornea  is  invaded  by  a  densely  vascular,  superficially 
ulcerated,  and  yet  thickened  zone.  It  is  to  be  distinguished 
from  a  deeper  variety  of  marginal  keratitis  alluded  to  at 
p.  140. 

In  another  variety  a  single  pustule  just  within  the  border 
of  the  cornea  ulcerates  deeply,  becomes  surrounded  by 
swollen,  softened,  suppurating  tissue,  and  may  perforate  : 
such  cases  are  seen  in  weakly  women  and  strumous  chil- 
dren. In  very  rare  cases,  what  appears  to  be  an  ordinary 
conjunctival  pustule,  persists,  grows  deeply,  and  may  even 


132  DISEASES     OF     THE     CORNEA. 

perforate  the  sclerotic  in  the  form  of  an  ulcer  ;  or  it  may- 
infiltrate  the  sclerotic  and  ciliary  body  beneath,  forming  a 
soft,  semi-suppurating  tumor,  whence  the  inflammation  is 
likely  to  spread  to  the  vitreous  and  destroy  the  eye.  Stop- 
ping short  of  these  extreme  results,  such  a  case  forms  one 
type  of  episcleritis.     Chapter  IX. 

Occasionally  a  large,  sometimes  solitary  blister  forms 
under  the  anterior  corneal  epithelium  ;  it  rises  quickly,  is 
attended  by  severe  neuralgic  pain,  which  is  often  relieved 
when  the  vesicle  bursts,  about  a  day  after  the  onset.  The 
condition  is  liable  to  relapse  in  the  same  cornea,  and  seems 
often,  though  not  ahva3'S,  to  have  its  origin  in  a  superficial 
injury.     See  Abrasion. 

The  corneal  changes  produced  by  the  friction  of  granular 
lids  have  been  considered  under  that  subject.  The  pannus 
of  granular  lids  usually  differs  from  the  "phlyctenular 
pannus  ''  just  mentioned  in  being  more  uniform  and  worse 
beneath  the  upper  lid,  Fig.  44  ;  any  doubt  is  dispelled  by 
everting  the  lid.  But  it  must  be  borne  in  mind  that  ulcer- 
ation of  the  cornea  often  occurs  as  a  complication  of  tracho- 
matous pannus. 

(4)  In  old  persons  a  crescentic  ulcer  sometimes  forms  in 
the  situation  of,  or  actually  upon,  an  arcus  senilis.  Though 
these  cases  generally  do  well,  they  should  be  watched,  for 
at  first  they  may  be  indistinguishable  from  more  serious 
forms  about  to  be  described. 

(5)  Infective  corneal  ulcers. — Several  varieties  of  dan- 
gerous corneal  ulcer  may  be  grouped  together  as  probably 
depending  upon  local  infection,  and  there  seems  to  be  no 
doubt  that  destructive  inflammation  of  the  cornea  may 
occur  in  utero.  Differing  widely  in  rapidity  and  depth, 
they  agree  in  being  often  the  result  of  slight  injuries  by 
chips  of  metal,  beards  of  corn,  etc.,  in  tending  to  spread  at 
one  border,  whilst  healing  at  another,  in  the  absence  of 
"  vessels  of  repair,"  such  as  are  usually  formed  during  the 


NON-SPECIFIC     INFLAMMATORY     DISEASES.       133 

healing  of  other    ulcers,  and  in  being  often  complicated 
with  hypopyon.     Fig.  48. 

The  most  important  variety  is  the  acute  serpiginous 
ulcer,  which  begins  as  a  gray  spot  showing  slight  ulceration, 
and  having  a  sharply-cut  border,  one  pa7't  of  which  is  more 

Fig.  47. 


Acute  serpig-inous  ulcer  of  cornea  with  crescentic  border  of  infiltration. 
(From  a  sketch  by  Dr.  Herbert  Habershon.) 

densely  opaque  than  the  rest,  Fig.  47  ;  this  infiltrated,  ad- 
vancing edge  is  the  distinguishing  mark  of  the  ulcer.  If 
the  ulcer  have  lasted  for  some  little  time,  a  portion  of  its 
edge,  usually  that  nearest  the  corneal  border,  will  be  more 
or  less  filled  up  ;  in  such  a  state  the  most  conspicuous  part 
of  the  ulcer  is  crescentic.  Fig.  47.  Unless  quickly  checked, 
the  process  often  spreads  widely,  eats  deeply,  becomes  com- 
plicated with  iritis  and  hypopyon,  and  leads  to  perforation 
of  the  cornea. 

Probably  man}^  cases  of  corneal  abscess  and  acute  sup- 
purating ulcer  of  less  distinct  type  than  the  above  are,  like 
it,  due  to  infection. 

Abscess  may  occur  at  any  age,  but,  like  serpiginous 
ulcer,  is  commonest  in  those  who  are  old,  underfed,  or 
damaged  by  drink  ;  but  the  little  gray  central  ulcers  of 
children  may  go  on  to  abscess.  Abscess  usually  forms  at 
the  centre  of  the  corneal  area  as  a  small,  round,  raised  spot, 
with  great  pain  and  congestion;  rapidly  enlarging,it  usually 
bursts  forward,  leaving  a  round  ulcer  covered  with  lymph\^ 


134 


DISEASES     OF     THE     CORNEA. 


pus,  but  it  may  perforate  the  hinder  surface  of  the  cornea; 
hypopyon  often  occurs.  The  purulent  infiltration  may 
spread  rapidly  and  destroy  almost  the  whole  cornea. 

Hypopyon  signifies  a  collection  of  pus  or  puro-lymph  at 
the  lowest  part  of  the  anterior  chamber  ;  its  upper  boundary 
is  usually,  but  not  always,  level.  Fig.  48.  It  may  occur 
with  any  ulcer,  whether  deep  or  not,  which  is  accompanied 


Fig.  48. 


Fig.  49. 


Hypopyon,  seen  from  the 
front,  and  in  section,  to 
show  that  the  pus  is  behind 
the  cornea. 


a.  Abscess,     h.  Onyx. 


by  purulent  infiltration  of  the  surrounding  cornea  ;  or  with 
corneal  abscess.  The  pus  may  be  derived  either  from  an 
abscess  breaking  through  the  posterior  surface  of  the 
cornea,  or  from  suppuration  of  the  epithelium  covering 
Descemet's  membrane,  or  from  the  surface  of  the  iris. 
Simple  iritis  now  and  then  gives  rise  to  hypopyon.  The 
diameter  of  the  anterior  chamber  being  rather  greater  than 
the  apparent  diameter  of  the  clear  cornea,  a  very  small  hy- 
popyon may  be  hidden  behind  the  overlapping  edge  of  the 
sclerotic.  In  some  cases  of  severe  corneal  suppuration 
(a,  Fig.  49)  the  pus  sinks  down  between  the  lamellae  of  the 
cornea  (6).  To  this  condition  the  term  onyx  is  applied  and 
should  be  limited,  though  it  is  sometimes  used  in  other 


NON-SPECIFIC     INFLAMMATORY     DISEASES.       135 

senses.  The  term,  however,  may  verv  well  be  discarded. 
Onyx  and  hypopyon  often  co-exist,  and  then  the  distinction 
between  them  can  hardly  be  made  without  tapping  the  ante- 
rior chamber.  Hypopyon,  if  liquid,  will,  but  onyx  will  not, 
change  its  position  if  the  patient  lies  down  ;  as,  however, 
the  pus  of  hypopyon  is  often  gelatinous  or  fibrinous,  this 
test  loses  much  of  its  value.  The  distinction  can  sometimes 
be  made  by  means  of  oblique  illumination,  if  the  cornea  in 
front  of  an  hypopyon  remain  clear. 

Chronic  and  subacute  serpiginous  ulcers  are  seen  from 
time  to  time  spreading  for  weeks  or  even  months.  They 
sometimes  have  the  form  above  described,  Fig.  47,  but 
occasionally  the  ulceration  takes  the  form  of  a  stem  with 
irregular  broad  buds  or  branches  not  unlike  a  liverwort, 
the  disease  being  superficial  from  beginning  to  end,  and 
showing  no  tendency  to  the  formation  of  pus,  but  spoiling 
the  surface  of  the  cornea — dendritic  creeping  ulcer. 

Treatment  of  ulcers  of  the  cornea. 

The  principles  of  local  treatment  for  the  various  types 
of  corneal  ulceration  are  :  (1)  To  favor  healing  by  keeping 
the  surface  at  rest.  (2)  To  relieve  pain,  photophobia,  and 
severe  congestion.  (3)  To  promote  absorption  of  pus, 
whether  in  the  corneal  layers  or  in  the  anterior  chamber. 
(4)  To  check  the  spread  of  local  infection  by  scraping, 
actual  cautery,  and  antiseptics.  (5)  By  incision  to  evacu- 
ate pus  between  the  corneal  layers  (abscess),  or  in  the 
anterior  chamber  (hypopyon),  when  abundant  or  increas- 
ing. (6)  To  stimulate  the  surface  of  ulcers  which  have 
begun  to  heal,  or  of  indolent  ones  which  are  stationary. 

(7)  Counter-irritation  by  a  seton  in  certain  chronic  cases. 

(8)  When  the  corneal  ulceration  is  caused  by  granular 
lids,  or  associated  with  any  form  of  acute  ophthalmia,  the 


13G  DISEASES     OF     THE     CORNEA. 

treatment  of  the  conjunctiva  is  usually  more  important 
than  that  of  the  cornea. 

Often  we  have  no  difficulty  in  deciding  upon  the  treat- 
ment ;  but  in  some  cases,  especially  the  severer  ones,  much 
judgment  is  needed,  and  it  is  sometimes  impossible  to 
predict  with  certainty  what  measures  will  be  best. 

Ulcers  of  the  cornea  are  so  often  a  sign  of  bad  health 
that  every  care  should  be  bestowed  upon  the  patient's 
general  state. 

Treating  the  matter  clinically,  we  shall  find  that  local 
stimulation  (6)  is  best  for  a  large  number  of  the  cases  as 
the}^  first  come  under  notice,  including  phlyctenular  cases, 
chronic  superficial  ulcers  of  various  kinds,  and  even  many 
recent  ulcers  if  not  threatening  to  suppurate.  As  a  general 
rule,  this  plan  alone  is  not  suitable  when  there  is  much 
photophobia  ;  but  exceptions  occur,  especially  in  old-stand- 
ing cases.  The  most  convenient  remedy  is  the  ointment  of 
amorphous  yellow^  oxide  of  mercury  (F.  12  and  13),  of 
w'hich  a  piece  about  as  large  as  a  hemp-seed  is  to  be  put  inside 
the  eyelids  once  or  twice  a  day.  If  smarting  continue  for 
more  than  half  an  hour,  the  ointment  should  be  washed  out 
with  warm  water ;  and  if  the  irritability  increase  after  a 
few  days'  use  of  the  ointment,  the  preparation  must  be 
weakened  or  discontinued.  The  same  ointment,  combined 
with  atropine,  gives  excellent  results  in  cases  of  superficial 
ulcer  with  much  photophobia  (F.  14).  Calomel  flicked 
into  the  eye  daily  or  less  often  is  also  an  admirable  remedy. 
Nitrate  of  silver  in  the  form  of  solid  mitigated  stick  (F.  1) 
is  useful  if  carefully  applied  to  large  conjunctival  pustules, 
and  occasionally  to  indolent  corneal  ulcers ;  its  use,  how- 
ever, needs  some  skill,  and  is  seldom  really  necessary  : 
solutions  of  from  5  to  10  grains  to  the  ounce  may  be  cau- 
tiously used  by  the  surgeon  instead  of  the  yellow  ointment, 
and  are  particularly  valuable  in  old  vascular  ulcers  and  in 
ulcers  with  conjunctivitis.     When  in  doubt  it  is  best  to 


NON-SPECIFIC     INFLAMMATORY     DISEASES.       187 

depend  for  a  few  days  on  atropine  alone,  used  once  or  twice 
a  day. 

Division  of  the  outer  canthus  by  scissors  is  sometimes 
employed  for  children  with  severe  photophobia,  but  is  only 
of  temporary  use ;  free  douching  of  the  head  and  face,  by 
putting  the  child's  head  under  a  tap  of  cold  water,  is  some- 
times successful.  In  all  cases  of  corneal  disease  attended 
with  intolerance  of  light,  the  patient  is  to  wear  a  large 
shade  over  both  eyes,  or,  better,  a  pair  of  "goggles;"  a 
little  patch  over  one  eye  does  not  relieve  photophobia. 
Many  a  child  is  kept  within  doors,  to  the  injury  of  its 
health,  who,  with  suitable  protection,  can  go  out  daily 
without  the  least  detriment  to  its  e3'es. 

In  chronic  and  relapsing  cases,  with  photophobia  and 
irritability,  where  other  methods  have  had  a  fair  trial,  a 
seton  gives  the  best  results,  whether  the  eye  be  much  con- 
gested or  not.  The  silk  must  be  very  thick  ;  the  punctures 
should  be  at  least  an  inch  apart,  and  be  so  placed  that  the 
scars  may  be  hidden  by  the  hair  on  the  temple  or  behind 
the  ear.  The  seton  is  to  be  moved  daily,  and  if  acting 
badly  may  be  dressed  with  savin  ointment ;  it  should  be 
worn  at  least  six  weeks.  Severe  inflammation,  and  even 
abscess,  sometimes  sets  in  a  few  days  after  the  insertion  of 
the  thread,  and  in  very  rare  cases  secondary  bleeding  has 
occurred  from  a  branch  of  the'temporal  artery.  To  avoid 
w^ounding  this  artery  the  skin  is  to  be  held  well  away  from 
the  head. 

Yery  severe,  recent  phlyctenular  cases  are  occasionally 
difficult  to  influence,  and  remain  practically  "blind''  with 
spasm  of  the  lids  for  weeks.  There  is  seldom  any  risk, 
provided  that  the  cornea  be  examined  at  intervals  of  a  few 
days,  and  in  the  end  such  cases  do  well.  Calomel  dusted 
on  the  cornea  sometimes  helps  more  than  any  other  local 
measure,  and  change  of  air,  especially  to  the  seaside,  fre- 
quently effects  a  more  rapid  cure  than  any  local  treatment. 


138  DISEASES     OF     THE     CORNEA. 

Cases  for  which  the  stimulating  treatment  is  suitable 
seldom  need  the  eye  to  be  banda<2^ed,  though,  as  mentioned, 
they  often  need  a  shade  or  goggles. 

The  remaining  methods  are  applicable  to  the  severer 
forms  of  ulceration — the  serpiginous  ulcer,  deep  suppurat- 
ing ulcers,  abscess,  and  generally  all  ulcers  with  hypopyon, 
and  all  acute  ulcers  in  elderly  persons.  In  many  cases  of 
severe  type,  at  an  early  stage,  the  pain  may  be  relieved 
and  the  ulceration  stopped  by  very  hot  fomentations  (of 
water,  poppy-head,  or  belladonna)  to  the  eyelids  for  twenty 
minutes  every  two  hours,  the  eye  being  tied  up  in  the  in- 
tervals with  a  large  pad  of  cotton-wool  and  bandage,  and 
atropine  used  two  or  three  times  a  day ;  the  patient  must 
rest,  have  good  food,  often  with  alcohol,  and  take  quinine, 
or  bark  and  ammonia.  If,  nevertheless,  the  ulceration 
spread,  or  an  hypopyon  form  or  increase,  incision  of  the 
cornea  and  the  use  of  topical  remedies  are  called  for.  Of 
such  remedies  the  best  seems  to  be  the  actual  cautery,  pre- 
ceded by  scraping  with  a  sharp  spoon,  and  followed  by 
iodoform  or  boracic  acid.  The  actual  cautery  may  be 
either  the  fine  galvano-cautery,  or  a  very  small  Paquelin  ; 
the  edge  of  the  ulcer  is  to  be  well  burnt  before  the  heat  is 
applied  to  the  floor,  and  I  like  to  burn  a  little  beyond  the 
opaque  edge. 

Iodoform,  which  is  probably  the  most  useful  corneal  anti- 
septic, may  be  used  in  powder  or  strong  ointment  (20  or 
30  gr.  to  ^j  ;  F.  19),  freely  three  times  a  day  or  more ;  it 
gives  no  pain.  Boracic  acid  may  be  used  in  the  same  way  ; 
perchloride  of  mercury,  of  the  strength  of  1  in  1000,  has 
also  been  used  in  cases  of  dendritic  creeping  ulcer. 

Hypopyon,  if  large,  Fig.  48,  or  increasing,  must  be  let 
out,  and,  on  the  whole,  for  most  cases,  Saemisch's  plan  of 
cutting  through  the  cornea  quite  across  the  ulcer  is  the 
best  for  this  purpose,  because  if  there  be  pent-up  pus  in  the 
cornea  this  section  will  allow  its  removal  at  the  same  time; 


NON-SPECIFIC    INFLAMMATORY    DISEASES.       139 

the  section  should  be  made  with  a  Graefe's  cataract  knife, 
Fig.  154,  entered  with  its  back  toward  the  lens  at  one  bor- 
der of  the  ulcer,  carried  across  the  anterior  chamber,  and 
brought  out  at  the  other  side  of  the  ulcer.  It  is  sometimes 
an  advantage  to  keep  up  leakage  by  reopening  the  wound 
with  a  probe  for  a  few  days.  Corneal  section  also  often 
instantly  relieves  the  severe  pain  of  these  cases,  and  it  has 
been  strongly  advocated  for  this  purpose  by  Mr.  Teale  and 
others.  The  section  may  sometimes  be  made  with  equally 
good  effect  in  the  lower  part  of  the  cornea  away  from  the 
ulcer.  If  the  ulcer  have  already  perforated  and  the  eye 
be  worth  saving,  iridectomy  should  be  done,  either  by  draw- 
ing the  prolapsed  iris  freely  through  the  perforation  and 
cutting  it  off,  or  by  making  an  incision  in  a  sound  part  of 
the  cornea.  I  believe  that  careful  scraping  and  burning 
will  do  much  to  reduce  the  severity  of  infective  corneal 
ulcers. 

Some  of  these  ulcers  are  accompanied  by  a  good  deal 
of  muco-purulent  conjunctivitis,  for  which  a  ten-grain  so- 
lution of  nitrate  of  silver,  painted  inside  the  lower  lid 
with  a  brush  about  once  a  day,  may  generally  be  used  ;  its 
effect  must  be  watched,  and  its  employment  discontinued 
if  it  increase  irritability. 

Use  of  atropine  and  eserine  in  severe  ulcers  of  the 
cornea.  Formerly  either  atropine  or  belladonna  lotion 
was  used  for  nearly  every  case  of  severe  corneal  ulcer. 
Atropine  often  relieves  pain,  prevents  or  lessens  iritis,  and 
probably  lessens  engorgement  of  the  vessels  of  the  iris  and 
ciliary  region  ;  it  may  generally  be  used,  sparingly,  as  an 
auxiliary  in  suppurating  and  serpiginous  cases.  But  atro- 
pine tends  to  increase  any  existing  conjunctival  inflam- 
mation, and  by  narrowing  the  area  and  contracting  the 
vessels  of  the  iris,  it  probably  retards,  rather  than  hastens, 
the  absorption  of  pus  in  the  anterior  chamber.  During 
the  last  few  years  eserine  has  come  into  use  for  certain 


140  DISEASES     OF     THE     CORNEA. 

cases  which  would  formerly  have  been  treated  chiefly  by 
atropine.  The  deep,  funnel-shaped,  suppurating  ulcer 
which  sometimes  develops  from  a  marginal  pustule  (p. 
131)  is  the  most  suitable  for  treatment  by  eserine,  whether 
complicated  with  hypopyon  or  not.  Although  in  a  bad 
case  of  this  sort,  hot  fomentations  and  the  compress  are 
necessary,  I  have  seen  a  certain  number  of  less  severe  ones 
recover  quickly  under  eserine  alone,  used  about  six  times 
a  day  (F.  35).  Eserine  probably  acts  partly  by  enlarging 
the  surface  of  the  iris  and  dilating  the  ciliary  arteries, 
and  thus  favoring  absorption  ;  possibly,  also,  it  acts  locally 
on  the  ulcerated  surface.  There  is  no  clinical  proof  that 
eserine  lowers  tension  unless  this  were  previously  in- 
creased, as  it  seldom  is  in  corneal  ulcers.  Eserine  causes 
congestion  of  the  deep  vessels  of  the  ciliary  region,  and 
after  a  time  increases  the  photophobia  and  irritability  of 
the  eye:  these  symptoms  usually  coincide  with  disappear- 
ance of  the  corneal  infiltration  and  the  commencement  of 
vascularization  of  the  ulcer,  and  when  this  stage  is  reached 
the  eserine  should  be  discontinued 

The  alternate  use  of  heat  and  cold  for  short  periods 
is  recommended  in  some  obstinate  cases  of  corneal  ulcer- 
ation, the  object  being  to  improve  nutrition  by  causing 
frequent  changes  in  the  quantity  and  rate  of  the  blood- 
supply. 

Rapidly  destructive  ulceration  of  the  cornea  is  common 
in  children  dying  of  meningitis,  and  is  probably  due  to 
the  exposure  and  drying  associated  with  the  patients'  semi- 
comatose state,  but  its  occasional  limitation  to  one  eye  sug- 
gests the  thought  that  it  may  be  in  part  directly  due  to 
trophic  influence.  Dr.  Barlow  tells  me  that  very  similar 
ulceration  may  occur  in  the  severe  exhaustion  following 
infantile  diarrhoea.  Ulceration  from  exposure  may  also 
occur  in  severe  cases  of  exophthalmic  goitre.  In  all 
the  above  cases  the  ulceration  usuall}'  takes  place  between 


NON-SPECIFIC    INFLAMMATORY    DISEASES.       141 

the  centre  and  the  lower  edge,  the  part  of  the  cornea 
which  is  last  covered  when  the  lids  are  closed  and  first 
exposed  when  they- are  opened. 

General  dense  opacity  of  the  cornea  occasionally»comes 
on  with  extreme  quickness  in  infants  who  are  recovering 
from  purulent  ophthalmia.  If  it  lead  to  destructive  ulcera- 
tion, the  term  kerato-malacia  hnot  inappropriate;  the  opac-' 
ity  sometimes,  however,  clears  up  in  a  remarkable  and  very 
unexpected  manner.  I  have  seen  two  such  recoveries  under 
the  use  of  eserine. 

Conical  cornea In  this  condition  the  central  part  of 

the  cornea  verv  slowly  bulges  forward,  forming  a  bluntly 
conical  curve.  The  focal  length  of  the  affected  part 
of  the  cornea  is  thereby  shortened,  and  the  eye  becomes 
myopic.  The  curvature,  however,  is  not  uniform,  and 
hence  irregular  astigmatism  complicates  the  myopia. 
Chapter  XX. 

The  disease,  which  is  rare,  occurs  chiefly  in  young  adults, 
especially  women,  and  is  often  associated  with  chronic 
dyspepsia ;  its  onset  is  sometimes  dated  from  a  severe, 
exhausting  illness ;  it  appears  to  be  due  to  defective 
nutrition  of  that  part  of  the  cornea  which  is  furthest 
from  the  bloodvessels.  In  advanced  cases  the  protrusion 
of  the  cornea  is  very  evident,  whether  viewed  from  the 
front  or  from  the  side,  but  slight  degrees  are  less  easily 
distinguished  from  ordinary  myopic  astigmatism.  In  high 
degrees  the  apex  of  the  cone,  which  is  situated  rather  below 
the  centre  of  the  cornea,  often  becomes  nebulous.  The 
disease  may  progress  to  a  high  degree,  or  stop  before  great 
damage  has  been  done.  Concave  glasses  alone  are  of  little 
use  ;  but  they  are  sometimes  useful  in  combination  with  a 
screen  perforated  by  a  narrow  slit  or  small  central  hole, 
which  allows  the  light  to  pass  only  through  the  centre,  or 
through  some  one  meridian  of  the  cornea.     In  advanced 


142  DISEASES     OF    THE    CORNEA. 

cases  an  operation  must  be  performed  which,  by  substi- 
tuting a  contracting  cicatrix  for  the  corneal  tissue  at  or 
near  the  apex  of  the  cone,  shall  lead  to  a  diminution  of 
the  cuiivature.     Chapter  XXII. 

B.  Diffuse  Keratitis. 

Syphilitic,  interstitial,  parenchymatous,  or  "  strumous^^ 
keratitis. 

In  this  disease  the  cornea  in  its  whole  thickness  under- 
goes a  chronic  inflammation,  which  shows  no  tendency 
either  to  the  formation  of  pus  or  to  ulceration.  After 
several  months  the  inflammatory  products  are  either  wholly 
or  in  great  part  absorbed,  and  the  transparency  of  the 
cornea  restored  in  proportion. 

The  changes  in  the  cornea  are  usually  preceded  for  a  few 
days  by  some  ciliary  congestion  and  watering.  Then  a 
faint  cloudiness  is  seen  in  one  or  more  large  patches,  and 
the  surface,  if  carefully  looked  at,  is  found  to  be  "  steamy  " 
(p.  126).     These  nebulous  areas  may  lie  in  any  part  of  the 

Fig.  50. 


Interstitial  keratitis. 

cornea.  In  from  two  to  about  four  weeks  the  whole  cornea 
has  usually  passed  into  a  condition  of  white  haziness  with 
steamy  surface,  of  which  the  term  "ground-glass"  gives 
the  best  idea.  Even  now,  however,  careful  inspection, 
especially  by  focal  light,  will  show  that  the  opacity  is  by 


DIFFUSE     KERATITIS 


143 


no  means  uniform,  that  it  shows  many  whiter  spots,  or 
larger  denser  clouds,  scattered  among  the  general  mist ;  in 
very  severe  cases  the  whole  cornea  is  quite  opaque  and  the 
iris  hidden  ;  but,  as  a  rule,  the  iris  and  pupil  can  be  seen, 
though  very  imperfectly.  Fig.  50.  In  many  cases  iritis 
occurs  and  posterior  synechiae  are  formed.  Bloodvessels 
derived  from  branches  of  the  ciliary  vessels,  Fig.  25,  are 
often  formed  in  the  layers  of  the  cornea,  Fig.  51 ;  they  are 
small  but  set  thickly,  and  in  patches ;  as  they  are  covered 
by  a  certain  thickness  of  hazy  cornea,  their  bright  scarlet 
is  toned  down  to  a  dull  reddish-pink  color  ("salmon 
patch"  of  Hutchinson).  The  separate  vessels  are  visible 
only  if  magnified,  when  we  see  that  the  trunks,  passing 
from  the  border,  divide  at  acute  angles  into  very  numerous 
twigs,  lying  close  to  each  other,  and  taking  a  nearly  straight 
course  toward  the  centre.  Fig.  52.  These  salmon  patches 
when  small  are  often  crescentic,  but  if  large  tend  to  assume 

Fig.  51. 


Thickening  of  cornea  and  formation  of  vessels  in  its  layers  in 
syphilitic  keratitis.  Subconjunctival  tissue  thickened.  X  about  10 
diameters.     Compare  with  Fig.  36. 


a  sector-shape.  In  another  type  the  vascularity  begins  as 
a  narrow  fringe  of  looped  vessels  which  are  continuous 
with  the  loop-plexus  of  the  corneal  margin,  Fig.  53,  com- 
pare Fig.  25,  /,  and  gradually  extend  from  above  and  below 


144  DISEASES     OF     THE     CORNEA. 

toward  the  centre.  The  vessels  in  these  cases  are  some- 
what more  superficial,  and  the  cornealtissue  in  which  they 
lie  is  always  swollen  by  infiltration.  This  type,  which  forms 
a  variety  of  ''marginal  keratitis,^''  compare  p.  131,  usually 

Fig.  52.  Fig.  53. 


Vessels  in  interstitial  Marginal  vascular  keratitis, 

keratitis. 


occurs  in  syphilitic  subjects,  but  I  believe  that  some  of  the 
patients  are  at  the  same  time  strumous.  A  similar  condi- 
tion, sometimes  leading  to  secondary  glaucoma,  occurs  now 
and  then  in  elderly  people.  In  extreme  cases  of  either 
type  of  vascular  keratitis  the  vessels  cover  the  whole 
cornea,  except  a  small  central  island. 

The  degree  of  congestion  and  the  subjective  symptoms 
in  syphilitic  keratitis  vary  very  much  ;  as  a  general  rule, 
there  is  but  moderate  photophobia  and  pain,  but  when  the 
ciliary  congestion  is  great  these  symptoms  are  sometimes 
very  severe  and  protracted. 

The  attack  can  be  shortened  and  its  severity  lessened  by 
treatment ;  but  the  disease  is  always  slow,  and  from  six  to 
twelve  months  may  be  taken  as  a  fair  average  for  its  dura- 
tion from  beginning  to  end.  Yery  bad  cases,  with  exces- 
sively dense  opacity,  sometimes  continue  to  improve  for 
several  years,  and  may  recover  an  unexpected  degree  of 


DIFFUSE     KERATITIS.  145 

sight.  Perfect  recovery  of  transparency  is  less  common, 
even  in  moderate  cases,  than  is  sometimes  supposed,  but  the 
slight  degree  of  haziness  which  so  often  remains  does  not 
much  affect  the  sight.  The  epithelium  usually  becomes 
smooth  before  the  cornea  becomes  transparent ;  but  in 
severe  cases  irregularities  of  surface  may  remain,  and  render 
the  diagnosis  difficult.  Yery  minute  vessels  (as  in  Fig.  52) 
seen  by  direct  ophthalmoscopic  examination  with  a  high 
4- lens  (p.  81),  nearly  straight,  and  branching  at  acute 
angles  with  short  abrupt  rectangular  bends  here  and  there, 
are  often  left,  and  when  found  are  good  evidence  of  pre- 
vious interstitial  keratitis. 

Syphilitic  keratitis  is  almost  always  symmetrical,  though 
an  interval  of  a  few  weeks  commonly  separates  its  onset  in 
the  two  eyes  :  rarely  the  interval  is  several  months,  a  year, 
or  even  more.  It  generally  occurs  between  about  the  ages 
of  six  and  fifteen  ;  sometimes  as  early  as  two  and  a  half  or 
three  years  ;  in  rare  instances  it  may  set  in  after  forty  ; 
many  of  the  very  late  cases  are  severe  and  complicated. 
If  it  occur  very  early  the  attack  is  generally  mild.  Re- 
lapses of  greater  or  less  severity  are  common.  Not  only 
does  iritis  occur  with  tolerable  frequency,  but  we  occasion- 
ally meet  with  deep-seated  inflammation,  in  the  ciliary 
region,  giving  rise  either  to  secondary  glaucoma,  or  to 
stretching  and  elongation  of  the  globe  in  the  ciliary  zone, 
or  to  softening  and  shrinking  of  the  eyeball.^  Dots  of 
opacity  may  sometimes  be  seen  on  the  back  of  the  cornea 
at  its  lower  part,  before  the  cornea  itself  is  much  altered  : 
sometimes,  too,  the  interstitial  exudation  is  much  more 
dense  at  the  lower  part  of  the   cornea   than   elsewhere. 

1  "When  the  cornea  has  cleared,  ophthalmoscopic  eigms  of  past  choroid* 
itis  (Chap.  XII.)  are  often  found  at  the  fundus.  The  choroiditis  often 
dates  much  further  back  than  the  keratitis,  but  there  is  little  doubt 
that  it  may  relapse,  or  occur  as  an  accompaniment  of  the  corneal  dis* 
ease.     (Chap.  XXIII.) 

7 


146  DISEASES    OP    THE     CORNEA. 

Syphilitic  keratitis  in  strumous  children  often  shows  more 
irritability,  photophobia,  and  conjunctival  congestion,  than 
in  others  ;  but  it  is  very  seldom  that  ulceration  occurs,  and 
although  in  the  worst  cases  the  cornea  becomes  softened 
and  yellowish,  and  for  a  time  seems  likely  to  give  way, 
actual  perforation  is  one  of  the  rarest  events.  Pannus 
from  granular  disease  may  coexist  with  syphilitic  keratitis. 

Treatment. — A  long  but  mild  course  of  mercury  is 
certainly  of  use.  It  is  customary  to  give  iodide  of  potassium 
also,  and  it  probably  has  some  influence.  If  the  patients 
be  very  anaemic,  and  they  often  are  so,  iron,  or  the  syrup  of 
its  iodide,  is  more  advisable  than  iodide  of  potassium  as  an 
adjunct  to  the  mercury.  Locally  it  is  well  to  use  atropine 
by  routine  until  the  disease  has  reached  its  height,  on  the 
ground  that  iritis  may  be  present.  Setons  in  my  experi- 
ence are  seldom  of  use;  but  in  cases  attended  by  severe 
and  prolonged  photophobia  and  ciliary  congestion  iridec- 
tomy is  occasionally  followed  by  rapid  improvement ;  this 
operation,  however,  is  seldom  needed  or  justifia])le  unless 
there  be  decided  glaucomatous  symptoms.  When  all 
inflammatory  symptoms  have  subsided,  the  local  use  of 
yellow  ointment  of  calomel  (F  11  and  12)  appears  to  aid 
the  absorption  of  the  residual  opacity. 

The  form  of  keratitis  above  described  is  caused  by 
inherited  syphilis.  In  rare  cases  it  has  been  seen  as  the 
result  of  secondary  acquired  syphilis.  Other  cases  of  diffuse 
keratitis  occur  in  w^hich  syphilis  has  no  share,  but  they  are 
seldom  symmetrical,  nor  do  they  occur  early  in  life.  That 
diffuse,  chronic  keratitis,  affecting  both  eyes  of  children 
and  adolescents,  is,  when  well  characterized,  almost  invari- 
ably the  result  of  hereditary  syphilis,  is  proved  by  abundant 
evidence.  A  large  proportion  of  its  subjects  show  some  of 
the  other  signs  of  hereditary  syphilis  in  the  teeth,  skin, 
ears  (deafness),  physiognomy,  mouth,  or  bones.  When  the 
patients  themselves  show  no  such  signs,  a  history  of  infantile 


DIFFUSE     KERATITIS.  147 

syphilis  in  the  patient  or  in  some  brothers  and  sisters,  or  of 
acquired  syphilis  in  one  or  other  parent,  may  often  be 
obtained.'  That  this  keratitis  stands  in  no  causal  relation 
to  struma,  is  clear,  because  the  ordinary  signs  of  struma  are 
not  found  oftener  in  its  victims  than  in  other  children, 
because  persons  who  are  decidedly  strumous  do  not  suffer 
from  this  keratitis  more  often  than  others,  and  because  the 
forms  of  eye  disease  which  are  universally  recognized  as 
"strumous"  (ophthalmia  tarsi,  phlyctenular  disease,  and 
relapsing  ulcers  of  cornea)  very  seldom  accompany  this 
diffuse  keratitis.  Illustrations  of  the  teeth  in  inherited 
syphilis  are  given  in  Fig.  164,  Chap.  XXIII. 

Other  Forms  of  Keratitis. 

Inflammation  of  the  cornea  forms  a  more  or  less  con- 
spicuous feature  in  several  diseases  where  the  primary,  or 
the  principal,  seat  of  mischief  lies  in  another  part  of  the 
eye.  It  is  important  for  purposes  of  diagnosis  to  compare 
these  secondary  or  complicating  forms  of  keratitis  with 
the  primary  diseases  of  the  cornea  already  described. 

In  iritis  the  lower  half  of  the  cornea  often  becomes 
steamy,  and  more  or  less  hazy.  In  some  cases  a  number 
of  small,  separate,  opaque  dots  are  seen  on  the  posterior 
elastic  lamina  (Descemet's  membrane),  often  so  minute  as 
to  need  magnifying.  These  dots  are  sharply  defined,  large 
ones  looking  very  like  minute  drops  of  cold  gravy-fat,  the 
smallest  like  grains  of  gray  sand ;  in  cases  of  long  standing 
they  may  be  either  very  white  or  highly  pigmented.  They 
are  generally  arranged  in  a  triangle,  with  its  apex  toward 
the  centre  and  its  base  at  the  lower  margin  of  the  cornea, 

^  I  have  found  other  personal  evidence  of  inherited  syphilis  in  oi 
per  cent,  of  my  cases  of  interstitial  keratitis,  and  evidence  from  the 
family  history  in  li  per  cent,  more  ;  total  68  per  cent.  ;  and  in  most  of 
the  remaining  32  per  cent,  there  have  been  strong  reasons  to  suspect  it. 


148  DISEASES     OF    THE    CORNEA. 

the  smallest  dots  being  near  the  centre,  Fig.  54  ;  but  in 
some  eases,  sympathetic  ophthalmitis,  especially,  the  dots 
are  scattered  over  the  whole  cornea.    They  are,  of  course. 

Fig.  54, 


Keratitis  punctata.     (From  a  sketch  by  Dr.  Herringham.) 

difficult  to  detect  in  proportion  as  the  corneal  tissue  itself 
is  hazy. 

The  term  heratitis  punctata  is  used  to  express  this  accu- 
mulation of  dots  on  the  back  of  the  cornea,  and  by  some 
authors  is  allowed  to  include  also  allied  cases  in  which 
small  spots  with  hazy  outlines  are  seen  in  the  cornea  proper. 
Keratitis  punctata  is,  almost  without  exception,  secondary 
to  some  disease  of  the  cornea,  iris,  or  choroid  and  vitreous. 
But  a  few  cases  are  seen,  chiefly  in  young  adults,  where 
the  corneal  dots  form  the  principal,  if  not  the  sole,  visible 
change  ;  the  number  of  such  cases  diminishes,  however,  in 
proportion  to  the  care  with  which  other  lesions  are  sought. 

It  is  now  and  then  difficult  to  say,  in  a  mixed  case, 
whether  the  iritis  or  keratitis  have  been  the  initial  change; 
but  when  this  doubt  arises  the  cornea  has  generally  been 
the  starting-point ;  and  with  care  we  are  seldom  at  a  loss 
to  decide  whether  the  case  be  one  of  syphilitic  keratitis 
with  iritis,  or  sclerotitis  with  corneal  mischief  and  iritis, 
or  of  primary  iritis  with  secondary  haze  of  cornea.  See 
Chaps.  YIII.  and  IX. 

Slight  loss  of  transparency  of  the  cornea  occurs  in  most 
cases  of  glaucoma.     The  earliest  change  is  a  fine,  uniform 


DIFFUSE    KERATITIS.  149 

feteaminess  of  the  epithelium.  In  very  severe,  acute  cases, 
the  cornea  becomes  hazy  throughout,  though  not  in  a  high 
degree.  The  same  haze  occurs  in  chronic  cases  of  long 
standing  with  great  increase  of  tension,  but  the  epithelial 
"  steaminess"  often  then  gives  place  to  a  coarser  "  pitting" 
with  little  depressions  and  elevations  (vesicles),  especially 
on  the  part  which  is  uncovered  by  the  lids. 

In  buphthalmos  (hydrophthalmos)  the  corneal  changes 
are  often  very  conspicuous,  although  not  essential.  In  this 
rare  and  very  peculiar  malady  there  is  general  and  slowly 
progressive  enlargement  of  cornea,  anterior  part  of  sclerotic, 
and  iris,  together  with  extreme  deepening  of  the  anterior 
chamber  and  slight  increase  of  tension.  The  cornea  often 
becomes  hazy  and  semi-opaque.  The  disease,  w^hich  may, 
perhaps,  be  looked  upon  as  a  congenital  or  infantile  form 
of  glaucoma,  is  either  present  at  birth  or  comes  on  in  early 
infancy,  and  usually  causes  blindness.  Operative  treat- 
ment generally  fails,  but  eserine  is  said  to  be  useful.  See 
Glaucoma. 

A  rare  but  peculiar  form  of  corneal  disease,  generally 
seen  in  elderly  persons,  is  the  transverse  calcareous  film, 
forming  an  oval  patch  of  light-gray  opacity,  w^hich  runs 
almost  horizontally  across  the  cornea.  It  lies  beneath  the 
epithelium,  and  consists  of  minute  crystalline  granules 
chiefly  calcareous. 

Arcus  senilis  is  caused  by  fatty  degeneration  of  the  cor- 
neal tissue  just  within  its  margin,  Fig.  55.  It  first  appears 
beneath  the  upper  lid,  next  beneath  the  low^er,  thus  form- 
ing tw^o  narrow,  white  or  yellowish  crescents,  the  horns  of 
which  finally  meet  at  the  sides  of  the  cornea  ;  it  always 
begins,  and  remains  most  intense,  on  a  line  slightly  within 
the  sclero-corneal  junction,  and  the  degeneration  is  most 
marked  in  the  superficial  layers  of  the  cornea  beneath  the 
anterior  elastic  lamina ;  in  other  w^ords,  the  change  is 
greatest  at  the  part  most  influenced  by  the  marginal  blood- 


150  DISEASES    OF     THE    CORNEA. 

vessels.  Arcus,  though  seldom  seen  except  in  senile  per- 
sons, is  not  found  to  interfere  with  the  union  of  a  wound 
carried  through  it,  though  the  tissue  of  the  arcus  is  often 
very  tough  and  hard. 

Fig.  55. 


Arcus  senilis.     (From  a  sketch  by  Dr.  Herringham.) 

Less  regular  forms  of  arcus  are  seen  as  the  result  of  pro- 
longed or  relapsing  inflammations  near  the  corneal  border, 
whether  ulcerative  or  not.  It  is  general!}^  easy  to  distin- 
guish such  an  arcus,  because  the  opacity  is  denser  and  more 
patchy,  and  its  outlines  are  less  regular  than  in  the  primary 
form;  when  arcus  is  seen  unusually  early  in  life  it  is  gen- 
erally of  this  inflammatory  kind,  for  simple  arcus  is  rare 
below  forty. 

Opacity  of  a  very  characteristic  kind  is  likely  to  follow 
the  use  ofa  lotion  containing  lead  when  the  surface  of  the 
cornea  is  abraded.  An  insoluble,  densely  opaque,  very 
white  film  of  lead  salts  is  precipitated  on,  and  adheres 
very  firmly  to,  the  ulcerated  surface ;  the  spot  is  sharply 
defined,  and  looks  like  white  paint.  If  precipitated  on  a 
deep  and  much  inflamed  ulcer,  the  layer  of  tissue  to  which 
the  film  adheres  is  often  thrown  off,  but  when  there  is  only 
a  superficial  abrasion  or  ulcer,  the  lead  adheres  very  firmly, 
and  can  only  be  scraped  off  imperfectly.  But  even  in  the 
latter  cases  the  film  is  probably,  after  a  time,  thrown  off  or 
worn  off,  if  we  may  judge  by  the  fact  that  nearly  all  the 
lead  opacities  which  come  under  notice  are  comparatively 


DIFFUSE     KERATITIS.  151 

new.  The  practical  lesson  is  never  to  use  a  lead  lotion  for 
the  eye  when  there  is  any  suspicion  that  the  corneal  surface 
is  broken. 

The  prolonged  use  of  nitrate  of  silver,  whether  in  a  weak 
or  strong  form,  is  sometimes  followed  by  a  dull,  brownish- 
green,  permanent  discoloration  of  the  conjunctiva,  and  even 
the  cornea  may  become  slightly  stained. 


CHAPTER    VIII. 

DISEASES    OF    THE    IRTS. 

Iritis. 

Inflammation  of  the  iris  may  be  caused  by  certain 
specific  blood  diseases,  especially  syphilis;  or  may  be  the 
expression  of  a  tendency  to  relapses  of  inflammation  in 
certain  tissues  under  the  influence  largely  of  climate  and 
weather — rheumatic  iritis  ;  it  often  occurs  in  the  course  of 
ulcers,  and  of  wounds  and  other  injuries  of  the  cornea; 
also  w^ith  diffuse  keratitis  and  sclerotitis.  Iritis  also  forms 
a  very  important  part  of  the  remarkable  and  serious  dis- 
ease know^n  as  sympathetic  ophthalmitis. 

Acute  iritis,  whatever  its  cause,  is  shown  by  a  change  in 
the  color  of  the  iris,  indistinctness  or  "muddiness"  of  its 
texture,  diminution  of  its  mobility  and  the  formation  of 
adhesions  {posterior  synechise)  between  its  posterior 
(uveal)  surface  and  the  capsule  of  the  lens;  there  is, 
besides,  in  most  cases,  a  dulness  of  the  whole  iris  and  pupil, 
caused  by  muddiness  of  the  aqueous  humor,  and  partly, 
also,  by  slight  corneal  changes.  The  eyeball  is  congested 
and  sight  usually  dimmed.  There  may  or  may  not  be 
pain,  photophobia,  and  lachrymation. 

The  congestion  is  often  almost  confined  to  a  zone  about 
one-twelfth  or  one-eighth  of  an  inch  wide,  which  surrounds 
the  cornea,  its  color  pink  (not  ra"w  red),  the  vessels  small, 
radiating,  nearly  straight,  and  lying  beneath  the  conjunc- 
tiva, ciliary  or  circumcorneal  congestion,  Fig.  28,  These 
are  the  episcleral  branches  of  the  anterior  ciliary  arteries, 


IRITIS.  153 

Fig.  25.  Quite  the  same  congestion  is  seen  in  many  other 
conditions,  e.  g.,  corneal  ulceration;  whilst  on  the  other 
hand,  in  some  cases  of  iritis,  the  superficial  (conjunctival) 
vessels  are  engorged  also,  especially  in  their  anterior  divi- 
sions, which  are  chiefly  offshoots  of  the  ciliary  system. 
We  therefore  never  diagnose  iritis  from  the  character  of 
the  congestion  alone  ;  but  the  disease  being  proved  by  the 
other  symptoms,  the  kind  and  degree  of  congestion  help  us 
to  judge  of  its  severity. 

The  altered  color  of  the  iris  is  due  to  its  congestion,  and 
the  effusion  of  lymph  and  serum  into  its  substance  ;  a  blue 
or  gray  iris  becomes  greenish,  a  brown  one  is  but  little 
changed.  The  inflammatory  swelling  of  the  iris  also  ac- 
counts both  for  the  blurring  (muddiness)  of  its  beautifully 
reticulated  structure,  and  for  the  sluggishness  of  movement 
noticed  in  the  early  period.  Lymph  is  soon  thrown  out  at 
one  or  more  spots  on  its  posterior  surface,  and  still  further 
hampers  its  movements  by  adhering  to  the  lens  capsule ; 
and  most  cases  do  not  come  under  notice  till  such  synechise 
have  formed.  The  quantity  of  solid  exudation,  whether  on 
the  hinder  surface  or  into  the  structure  of  the  iris,  varies 
much ;  it  is  usually  greatest  in  syphilitic  iritis,  when  distinct 
nodules  of  pink  or  yellowish  color  are  sometimes  seen  pro- 
jecting from  the  front  surface,  generally  close  to  the  pupil. 
In  rare  cases  pus  thrown  off  by  the  iris  into  the  aqueous 
subsides  and  forms  hypopyon  ;  a  corresponding  deposit  of 
blood  constitutes  hyphasmia.  Firm  adhesions  to  the  lens 
capsule  may  be  present  without  much  evidence  of  exuda- 
tion into  the  structure  of  the  iris.  Exudative  changes  are 
usually  most  abundant  at  the  inner  ring  of  the  iris,  w^here 
its  capillary  vessels  are  far  the  most  numerous.    Fig.  56. 

Apparent  discoloration  of  the  iris  is,  however,  often  due 
entirely  to  suspension  of  blood-corpuscles,  or  inflammatory 
products  in  the  aqueous  humor ;  sometimes  this  altered 
fluid  coagulates  into   a  slightly  turbid  gelatinous  mass, 


154 


DISEASES     OF     THE     1RI8 


which  almost  fills  the  chamber  ("spongy  exudation"). 
The  aqueous  sometimes  becomes  yellow  without  losing 
transparency. 

Fig.  56. 


Vessels  of  human  iris  artificially  injected  ;  capillaries  most  numerous  at 
pupillary  border,  and  next  at  ciliary  border. 

The  tension  of  the  eyeball,  usually  unaltered  in  acute 
iritis,  may  be  a  little  increased ;  rarely  it  is  considerably 
diminished,  and  in  such  cases  there  are  generally  other 
peculiarities. 

The  condition  of  the  pupil  alone  is  diagnostic  in  all 
except  very  mild  or  incipient  cases  of  iritis.  It  is  sluggish 
or  motionless,  and  not  quite  round  ;  it  is  also  rather  smaller 
than  its  fellow  (supposing  the  iritis  to  be  one-sided), because 
the  surface  of  the  iris  is  increased  (and  the  pupil,  therefore, 
encroached  on)  whenever  its  vessels  are  distended.  Atro- 
pine causes  it  to  dilate  between  the  synechiae  ;  the  synechias 
being  fixed,  appear  as  angular  projections  when  the  iris  on 
each  side  of  them   has  retracted.     If  there  be   only  one 


IRITIS. 


155 


adhesion  it  will  merely  notch  the  pupil  at  one  spot ;  if  the 
adhesions  be  numerous  the  pupil  will  be  crenated  or  irreg- 
ular, Fig.  57.  If  the  whole  papillary  ring,  or  still  more,  if 
the  entire  posterior  surface  of  the  iris  be  adherent,  scarcely 
any  dilatation  will  be  effected  ;  the  former  condition  is 
called  annular  or  circular  synechia,  and  its  result  is  ''exclu- 
sion "  of  tJie  pupil ;  the  latter  is  known  as  total  posterior 


Fig.  57. 


Fig.  58. 


# 


Iritic  adhesions  (posterior  synechife) 
causing  irregularity  of  pupil.  (  Wecker 
and  Jaeger.) 


Spots  of  pigment  and 
lymph  at  seat  of  former 
iritic  adhesions. 


synechia.  If  the  synechiae  be  new  and  the  lymph  soft  the 
repeated  use  of  atropine  will  break  them  down  and  the 
pupil  become  round  ;  but  even  then  some  of  the  uveal  pig- 
ment, which  is  easily  separable  from  the  posterior  surface 
of  the  iris,  often  remains  behind,  glued  to  the  lens  capsule 
by  a  little  lymph,  Fig.  58.  The  presence  of  one  or  more 
such  spots  of  brown  pigment  on  the  capsule  is  always  con- 
clusive proof  of  present  or  of  past  iritis.  T  he  pupillary  area 
itself  in  severe  iritis  is  often  filled  by  grayish  or  yellowish 
lymph,  which  spreads  over  it  from  the  iris  ;  if  such  exuda- 
tion become  organized  a  dense  white  membrane  or  a  delicate 
film  (often,  however,  presenting  one  or  more  little  clear 
holes),  is  formed  over  the  pupil  ("  occlusion^^  of  the  pupil). 
The  iris  may  be  inflamed  without  any  lymph  being  effused 
from  its  hinder  surface,  and  then  the  pupil,  though  slug- 
gish, acting  imperfectly  to  atropine,  and  never  dilating 
widely,  wnll  present  no  posterior  synechiae  nor  any  adhesion 


156  DISEASES     OF     THE     IRIS. 

of  pigment  spots  to  the  lens,  but  it  will  always  be  discol- 
ored (serous  iritis)  ;  iritis  of  this  kind  often  occurs  with 
ulceration  of  the  cornea,  and  as  a  complication  of  deeper 
inflammations. 

Pain  referred  to  the  eyeball  and  to  the  parts  supplied  by 
the  first,  and  sometimes  by  the  second  division  of  the  fifth 
nerve,  is  common  with  iritis,  especially  in  the  early  period. 
It  is,  however,  a  very  variable  symptom,  and  gives  no  clue 
to  the  amount  of  structural  change,  being  sometimes  quite 
insignificant  when  much  lymph  is  thrown  out.  The  pain 
is  seldom  constant,  but  comes  on  at  intervals,  is  often  worst 
at  night,  and  is  described  as  shooting,  throbbing,  or  aching. 
It  is  commonly  referred  to  the  temple  or  forehead,  as  well 
as  to  the  eyeball ;  sometimes  also  to  the  side  of  the  nose 
and  to  the  upper  teeth.  Photophobia  and  w^atering  are 
generally  proportionate  to  the  pain. 

The  duration  of  acute  iritis  varies  from  a  few^  days  when 
mild,  to  many  wrecks  when  severe.  The  defect  of  sight  is 
proportionate  to  the  haziness  of  the  cornea,  aqueous,  and 
])upillary  space,  but  in  some  cases  is  increased  by  changes 
in  the  vitreous.  Iritis  sometimes  sets  in  very  gradually, 
caufsing  no  marked  congestion  or  pain,  but  slowly  giving 
rise  to  the  formation  of  tough  adhesions,  and  often  to  the 
growth  of  a  thin  membrane  over  the  pupillary  area;  in 
some  of  these  cases  the  iris  becomes  thickened  and  tough, 
and  its  large  vessels  undergo  much  dilatation,  w^hilst  in 
others  keratitis  punctata  occurs.  See  Cyclitis,  Chap.  IX., 
Diseasesof  Cornea,  p.  147;  and  Sympathetic  Ophthalmitis, 
Chap.  IX. 

Permanent  results  of  iritis. — Reference  has  been  made 
to  the  adhesions,  which  are  often  permanent,  and  to  the 
spots  of  uveal  pigment  on  the  lens  capsule,  w^hich  are 
ahvays  so  ;  either  condition  tells  a  tale  of  past  iritis,  and  is 
thus  a  valuable  aid  to  diagnosis.  A  blue  iris  which  has 
undergone    .severe    inflammation    may    remain    greenish. 


RITIS 


157 


Patches  of  atrophy  may  follow  severe  plastic  exudations 
into  the  iris,  and  are  recognized  by  their  whitish  color  and 
thinness.  Large  patches  of  new  pigment  occasionally  form, 
extending  from  the  pupillary  border  on  the  anterior  surface. 
When  the  pupil  is  "excluded"  or  "  occluded,"  the  re- 
mainder of  the  iris  being  free,  fluid  collects  in  the  posterior 
aqueous  chamber,  and  by  bulging  the  iris  forward,  and 
diminishing  the  depth  of  the  anterior  chamber,  except  at 
its  centre,  gives  the  pupil  a  funnel-like  appearance ;  if  the 
bulging  be  partial,  or  be  divided  by  bands  of  tough  mem- 
brane, the  iris  looks  cystic.  Secondary  glaucoma  is  likely 
to  follow,  and  the  tension  of  the  globe  should,  therefore, 
be  carefully  noted  whenever  bulging  is  present ;  in  not  a 

Fig.  59. 


Diagram  to  show  the  result,  upon  the  iris,  of  exclusion  of  the  pupil 
(p.  15r>).     (From  a  specimen.) 


few  of  these  cases,  however,  we  find  the  eye  soft  and  begin- 
ning to  shrink,  the  sequel,  perhaps,  of  a  glaucomatous 
state.  "  Total  posterior  synechia"  always  shows  a  severe, 
though  often  a  chronic,  iritis;  it  is  often  accompanied  by 
deep-seated  disease,  and  followed  by  opacity  of  the  lens, 
secondary  cataract,  and  in  some  cases  ultimately  the  lens 


158  DISEASES    or     THE     IRIS. 

becomes  absorbed.  Relapses  of  iritis  are  believed  to  be 
induced  by  the  presence  of  synechiae,  even  where  there  is 
no  protrusion  of  the  iris  by  fluid;  but  their  influence  in 
this  direction  has,  I  believe,  been  much  overrated. 

It  must,  however,  be  observed  that  there  is  still  much  differ- 
ence of  opinion  on  the  point  last  referred  to.  The  iritis  of 
syphilis  is  still  held  b}-  some  to  be  liable  to  recur,  and  to  be  by 
no  means  limited  to  the  secondary  stage :  and  we  still  often  he  ar 
it  stated  that  iritic  adhesions,  by  preventing  free  movement  of 
the  iris,  operate  as  sources  of  irritation,  and  thus  predispose  to 
relapse.  I  have  seldom  succeeded  in  getting  a  history  of  recent 
syphilis  in  cases  of  recurring  iritis,  whilst  in  a  number  of  cases 
of  old  iritis  with  the  history  that  the  attack  occurred  durin  g 
secondary  syphilis  years  before,  I  have  scarcely  found  one  with 
well-marked  history  of  relapses.  On  the  other  hand,  I  have 
several  times  seen  severe  relapses  in  rheumatic  cases  after  iri- 
dectomy had  been  performed  as  a  preventive.  All  the  evidence 
seems  to  me  to  favor  the  view  that  recurrences  of  iritis  depend, 
as  a  rule,  upon  the  constitutional  cause  of  the  disease. 

The  following  are  the  most  important  points  as  to  the 
causes  of  iritis,  and  the  chief  clinical  diflferences  between 
the  several  forms. 

Constitutional  Causes.  Syphilis. — The  iritis  is  acute  ; 
it  shows  a  great  tendenc}'  to  eff'usion  of  lymph  and  forma- 
tion of  vascular  nodules  (plastic  iritis),  and  the  nodules, 
when  very  large,  may  even  suppurate ;  it  is  symmetrical 
in  a  large  proportion,  probably  at  least  two-thirds,  of  the 
cases.  But  asymmetry  and  absence  of  lymph-nodules  are 
common.  It  occurs  only  in  secondary  syphilis,  either  ac- 
quired or  inherited,  and  seldom  relapses.  Its  significance 
is  thus  entirel}^  diS'erent  from  that  of  the  iritis  which  often 
complicates  syphilitic  keratitis. 

Bheamatism  is  the  cause  of  most  cases  of  relapsing  un- 
symmetrical  iritis ;  there  is  but  little  tendency  to  eff'usion 
of  lymph,  and  nodules  are  never  formed,  but  there  is  occa- 


IRITIS.  159 

sionally  fluid  hypopyon ;  the  congestion  and  pain  are  often 
more  severe  than  in  syphilitic  iritis.  An  attack  is  usually 
unsymmetrical,  though  both  eyes  commonly  suffer  by  turns. 
It  relapses  at  intervals  of  months  or  years.  E  ven  repeated 
attacks  sometimes  result  in  but  little  damage  to  sight. 
Gout  is  apparently  a  cause  of  some  cases  of  both  acute  and 
insidious  chronic  iritis.  It  is  perhaps  doubtful  whether 
the  gout  or  the  chronic  rheumatism  from  which  the  same 
patients  sometimes  suffer  is  the  cause  of  the  iritis.  In  its  ten- 
dency to  relapse,  and  to  affect  only  one  eye  at  a  time,  gouty 
resembles  rheumatic  iritis.  The  children  of  gouty  parents 
are  occasionally  liable  to  a  very  insidious  and  destructive 
form  of  chronic  iritis,  with  disease  of  the  vitreous,  keratitis 
punctata,  and  glaucoma.     Chaps.  IX.  and  XXIII. 

Chronic  iritis  {plastic  irido-choroiditis). — In  a  few 
cases  symmetrical  iritis,  of  a  chronic,  progressive,  and  de- 
structive character,  is  complicated  with  choroiditis,  disease 
of  vitreous,  and  secondary  cataract.  These  cases,  for  which 
it  is  at  preseni  impossible  to  assign  any  cause,  either  gen- 
eral or  local,  are  chiefly  seen  in  adults  below  middle  life. 

Sympathetic  iritis — See  Sympathetic  Ophthalmitis. 

Local  Causes.  Injuries. — ^Perforating  wounds  of  the 
eyeball,  particularly  if  irregular,  contused,  and  complicated 
with  wound  of  the  lens,  are  often  followed  by  iritis,  and 
more  often  if  the  patient  be  old  than  young.  If  the  cor- 
neal wound  suppurate,  or  become  much  infiltrated,  the 
iritis  is  likely  to  be  suppurative,  and  the  inflammation  to 
spread  to  the  ciliary  processes  and  cause  destructive  pan- 
ophthalmitis. Iritis  may  follow  a  wound  of  the  lens-cap- 
sule without  wound  of  the  iris,  and  with  only  a  mere 
puncture  of  the  cornea.  Examples  of  traumatic  iritis  from 
these  several  causes  are  seen  after  the  various  operations 
for  cataract.  The  iritis,  or  more  correctly  irido-capsulitis, 
following  extraction  of  senile  cataract  is  often  prolonged, 
attended  by  chemosis,  much  congestion,  and  the  formation 


160  DISEASES     OF     THE     IRIS. 

of  tough  membrane  behind  the  iris.  Iritis  may  also  follow 
superficial  wounds  and  abrasions  of  the  cornea,  or  direct 
blows  on  the  eye  ;  but  it  is  of  great  importance,  whenever 
the  question  of  injury  comes  in,  to  ascertain  whether  or 
not  there  has  been  a  perforating  wound.  Iritis  often  ac- 
companies ulcers  and  other  inflammations  of  the  cornea, 
especially  when  deep,  or  complicated  with  hypopyon,  or 
occurring  in  elderly  persons.  Iritis  may  accompany  deep- 
seated  disease  of  the  eye. 

Treatment. — (1)  In  every  case  where  iritis  is  present 
atropine  is  to  be  used  often  and  continuously,  in  order  to 
break  down  adhesions  already  formed,  and  to  allow  any 
lymph  subsequently  effused  to  be  deposited  outside  the 
ordinary  area  of  the  pupil.  A  strong  solution,  four  grains 
of  sulphate  of  atropine  to  one  ounce  of  distilled  water,  is 
to  be  dropped  into  the  conjunctival  sac  every  hour  in  the 
early  period.  Even  if  the  synechias  are,  when  first  seen, 
alread}^  so  tough  that  the  atropine  has  no  effect  on  them,  it 
may  prevent  the  formation  of  new  ones  on  the  same  circle. 
Atropine  also  greatly  relieves  pain  in  iritis,  and  lessens  the 
congestion,  and  through  these  means  it  no  doubt  helps  ma- 
terially to  arrest  exudation.  Mild  acute  iritis  may  some- 
times be  cured  by  atropine  alone. 

(2)  If  there  be  severe  pain  with  much  congestion,  three 
or  four  leeches  should  be  applied  to  the  temple,  to  the 
malar  eminence,  or  to  the  side  of  the  nose.  They  may  be 
repeated  daily,  in  the  same  or  smaller  numbers,  with  ad- 
vantage, for  several  days,  if  necessary;  or,  after  one  leech- 
ing, repeated  blistering  may  be  substituted.  Some  surgeons 
use  opiates  instead  of,  or  in  addition  to,  leeches.  Leeches 
occasionally  increase  the  pain.  Severe  pain  in  iritis  can 
nearly  always  be  quickly  relieved  by  artificial  heat,  either 
fomentations  or  dry  heat,  as  hot  as  can  be  borne,  to  the 
eyelids.  To  apply  dry  heat,  take  a  piece  of  cotton-wool 
the  size  of  two  fists,  hold  it  to  the  fire  or  against  a  tin  pot 


IRITIS.  161 

full  of  6o27i>?^  water,  till  quite  hot,  and  apply  it  to  the  lids; 
have  another  piece  ready,  and  change  as  soon  as  the  first 
gets  cool ;  continue  this  for  twenty  minutes  or  more,  and 
repeat  it  several  times  a  day.^  Paracentesis  of  the  anterior 
chamber  should  be  resorted  to  in  severe  iritis  if  the  aque- 
ous humor  remain  very  turbid  after  a  few  days  of  other 
treatment ;  it  may  be  repeated  every  day  or  two  unless 
there  is  marked  improvement. 

(3)  Rest  of  the  eye  is  very  important.  Many  an  attack 
is  lengthened  out,  and  many  a  relapse  after  partial  cure  is 
brought  on,  by  the  patient  continuing  at,  or  returning  too 
soon  to,  work.  It  is  not  in  most  cases  necessary  to  remain 
in  a  perfectly  dark  room  ;  to  wear  a  shade  in  the  room  with 
the  blinds  down  is  generally  enough,  provided  that  no  at- 
tempt be  made  to  use  the  eyes.  Work  should  not  be 
resumed  till  at  least  a  week  after  all  congestion  has 
gone  off. 

(4)  Cold  draughts  of  air  on  the  eye  and  all  causes  of 
"  catching  cold  "  are  to  be  very  carefully  avoided  by  keep- 
ing the  eye  warmly  tied  up  with  a  large  pad  of  cotton 
wool. 

(5)  The  cause  of  the  disease  is  to  be  treated,  and  into 
this  careful  inquiry  should  always  be  made.  If  the  iritis 
be  syphilitic,  treatment  for  secondary  syphilis  is  proper, 
mercury  being  given  just  short  of  salivation  for  several 
months,  even  though  all  the  active  eye  symptoms  quickly 
pass  off.  The  rheumatic  and  gouty  varieties  are  less  defi- 
nitely under  the  influence  of  internal  remedies:  iodide  of 
potassium,  alkalies,  colchicum,  salicylate  of  soda,  and  tur- 
pentine, each  have  their  advocates  ;  when  the  pain  is  severe 
tincture  of  aconite  is  sometimes  markedly  useful ;  mercury 
is  seldom  needed,  but  in  protracted  and  severe  cases  it  may 
be  given  with  advantage.     It  is  sometimes  advisable  to 

1  1  owe  my  knowledge  of  the  value  of  dry  heat  to  Mr.  Llebreich. 


162  DISEASES     OP    THE     IRIS. 

combine  quinine  or  iron  with  the  mercury  in  syphilis,  or 
to  g-ive  them  in  addition  to  other  remedies  in  rheumatic 
cases. 

(6)  As  a  rule  no  stimulants  are  to  be  allowed,  and  the 
bowels  should  be  kept  well  open. 

(7)  Iridectomy  is  needed  for  cases  of  severe  iritis,  even 
when  there  is  no  increase  of  tension,  if  judicious  local  and 
internal  treatment  have  been  carefully  tried  for  some  weeks 
without  marked  relief  to  the  symptoms.  It  is  chiefly  in 
cases  of  constitutional  origin,  either  syphilitic  or  rheumatic, 
and  in  the  iritis  accompanying  ulcers  of  the  cornea,  that 
iridectomy  is  useful ;  it  is  not  admissible  in  sympathetic 
iritis,  nor  in  iritis  after  cataract  extraction.  Iridectomy 
has  been  largely  employed  to  prevent  relapses  of  iritis,  but 
the  operation  has  much  less  effect  in  this  way  thaa  has 
often  been  supposed  ;  it  should  not,  therefore,  be  employed 
until  the  other  means  of  cure  have  been  fairly  tried.  It 
must  be  borne  in  mind,  that  unless  iridectomy  is  necessary, 
it  is  injurious,  by  producing  an  enlarged  and  irregular 
pupil  through  which,  for  optical  reasons,  the  patient  will 
often  not  see  so  well  as  through  the  natural  pupil,  even 
though  this  be  partially  obstructed.  In  regard  to  all 
methods  of  local  treatment  we  must  bear  in  mind  that  acute 
iritis  occurs  in  all  degrees  of  severity,  and  that  the  mildest 
cases  often  need  only  atropine  and  rest. 

Traumatic  iritis,  in  the  earliest  stage,  is  best  combated 
by  atropine,  continuous  cold  obtained  by  laying  upon  the 
closed  eyelids  pieces  of  lint  wetted  in  iced  water  and 
changed  every  few  minutes,  and  by  leeches.  Gold  is  not 
to  be  used  in  any  other  form  of  iritis,  and  is  useless  even  for 
traumatic  cases  after  the  first  day  or  so  ;  later,  warmth  is 
more  appropriate. 

Congenital  irideremia  (absence  of  iris)  is  occasionally 
seen,  and  is  often  associated  with  other  defects  of  the  eye, 
especially  opacities  in  the  lens. 


IRITIS.  163 

Coloboma  of  the  iris  (congenital  developmental  cleft  in 
the  iris)  giv'es  the  effect  of  a  very  regularly  made  iridec- 
tomy. It  is  always  downwards  or  slightly  down-in,  and  is 
often,  but  not  always,  symmetrical.  It  occurs  in  different 
degrees,  and  sometimes  a  mere  line  or  seam  in  the  iris  indi- 
cates the  slightest  form  of  the  defect.  It  often  occurs 
without  coloboma  of  the  choroid. 

Pupillary  and  capsule-pupillary  membranes. — In  early 
foetal  life,  the  capsule  of  the  lens  is  vascular,  supplied  with 
blood  by  the  hyaloid  artery ;  when  the  iris  grows  in  from 
the  anterior  part  of  the  choroid,  and  comes  into  contact 
with  the  capsule,  its  vessels  anastomose  with  those  of  the 
capsule,  and  the  membrane  so  formed  fills  the  pupil.  Nor- 
mally this  membrane  disappears  entirely  with  the  vessels 
of  the  lens  capsule;  sometimes  the  part  attached  to  the 
capsule  only  disappears,  leaving  behind  the  anterior  part 
of  the  structure,  which  is  known  as  the  pupillary  mem- 
brane. In  this,  bands  of  tissue,  resembling  that  of  the 
iris,  run  from  one  part  of  the  anterior  surface  of  the  iris 
to  another,  springing  from  near  the  pupillary  edge.  Some- 
times the  whole  thickness  of  the  membrane  remains,  in 
which  case  bands  of  tissue  pass  from  the  anterior  surface 
of  the  iris  to  the  capsule  ;  this  forms  the  capsulo-pupillary 
membrane.  Some  of  the  latter  cases  have  probably  been 
described  as  the  remains  of  intra-uterine  iritis. 


CHAPTER    IX. 

DISEASES   OF    THE    CILIARY    REGION. 

This  chapter  is  intended  to  include  cases  in  which  the 
ciliary  body  itself,  or  the  corresponding  part  of  the  sclerotic, 
or  the  episcleral  tissue,  is  the  sole  seat,  or  at  least  the 
headquarters,  of  disease.  From  the  abundance  of  vessels 
and  nerves  in  the  ciliary  body,  and  the  importance  of  its 
nutritive  relations  to  the  surrounding-  parts,  we  find  that 
many  of  the  morbid  processes  of  the  ciliary  region  show  a 
strong  tendency  to  spread,  according  to  their  precise  posi- 
tion and  depth,  to  the  cornea,  iris,  or  vitreous,  and,  by 
influencing  the  nutrition  of  the  lens,  to  cause  secondary 
cataract.  Although  alike  on  pathological  and  clinical 
grounds  it  is  necessary  to  subdivide  the  class  into  groups, 
we  may  observe  that  the  various  diseases  of  this  part  show 
a  general  agreement  in  some  of  their  more  important 
characters ;  thus  all  of  them  are  protracted  and  liable  to 
relapse,  and  in  all  there  is  a  marked  tendency  to  patchiness, 
the  morbid  process  being  most  intense  in  certain  spots  of 
the  ciliary  zone,  or  even  occurring  in  quite  discrete  areas. 
It  is  convenient  to  make  three  principal  clinical  groups, 
the  differences  between  w^hich  are  accounted  for  to  a  great 
extent  by  the  depth  of  the  tissue  chiefly  implicated.  The 
most  superficial  may  be  taken  first. 

(1)  Episcleritis  (more  correctly  Scleritis)  is  the  name 
given  to  one  or  more  large  patches  of  congestion  in  the 
ciliary  region,  with  some  elevation  of  the  conjunctiva  from 
thickening  of  the  subjacent  tissues.  The  congestion  gen- 
erally affects  the  conjunctival  as  well  as  the  deeper  vessels, 


DISEASES     OP    THE     CILIARY     REGION.        165 

and  the  yellowish  color  of  the  exudation  tones  the  brig-ht 
blood-red  down  to  a  more  or  less  rusty  tinge,  which  is 
especially  striking  at  the  central,  thickest  part  of  the 
patch.  The  thickening  seldom  causes  more  than  a  low, 
widely-spread  mound  of  swelling. 

Episcleritis  is  a  rather  rare  disease.  It  occurs  chiefly  on 
the  exposed  parts  of  the  ciliary  region,  and  especially  near 
the  outer  canthus;  but  the  patches  may  occur  at  any  part 
of  the  circle,  and  exceptionally  the  inflammation  is  difl'used 
over  a  much  wider  area  than  the  ciliary  zone,  extending 
far  back,  out  of  view.  The  iris  is  often  a  little  discolored 
and  the  pupil  sluggish,  but  actual  iritis  is  the  exception. 
There  is  often  much  aching  pain.  The  disease  is  subacute, 
reaching  its  acme  in  not  less  than  two  or  three  weeks,  and 
requiring  a  much  longer  time  before  absorption  is  complete. 
Fresh  patches  are  apt  to  spring  up  while  old  ones  are  de- 
clining, and  so  the  disease  may  last  for  months ;  indeed, 
relapses  at  intervals,  and  in  fresh  spots,  are  the  rule.  It 
usually  affects  only  one  eye  at  a  time,  but  both  often  suffer 
sooner  or  later.  After  the  active  changes  have  disappeared, 
a  patch  of  the  underlying  sclerotic,  of  rather  small  size,  is 
generally  seen  to  be  dusky,  as  if  stained ;  it  is  doubtful 
whether  such  patches  represent  thinning  of  the  sclerotic 
from  atrophy,  or  only  staining;  it  is  but  seldom  that  they 
show  any  tendency  to  bulge  as  if  thinned.  In  rare  cases 
the  exudation  is  much  more  abundant,  and  a  large  swell- 
ing is  formed,  which  may  even  contain  pus ;  such  cases 
pass  by  gradations  into  conjunctival  phlyctenulge,  and  are 
generally  seen  in  children. 

Episcleritis  is  seldom  seen  except  in  adults,  and  is  com- 
moner in  men  than  women.  Inquiry  often  shows  that  the 
sufferer  is,  either  from  occupation  or  temperament,  particu- 
larly liable  to  be  affected  by  exposure  to  cold  or  by  changes 
of  temperature.  Some  of  the  patients  are  rheumatic,  some 
gouty.  Similar  patches,  but  of  brownish,  rather  translucent 


166        DISEASES    OF    THE     CILIARY    REGION. 

appearance,  are  occasioually  caused  by  tertiary  syphilis, 
acquired  or  inherited  (gummatous  scleritis). 

In  the  treatment,  protection  by  a  warm  bandage,  rest, 
the  yellow  ointment  (F.  12),  the  use  of  repeated  blisters, 
and  local  stimulation  of  the  swelling,  are  generally  the 
most  efficacious.  Atropine  is  very  useful  in  allaying  pain. 
Internal  remedies  seldom  seem  to  exert  much  influence, 
except  in  syphilitic  cases.  Salicylate  of  soda  has  been 
highly  spoken  of  by  some.  Systematic  kneading  of  the 
eye  through  the  closed  lids  ("massage"),  and  scraping 
away  the  exudation  with  a  sharp  spoon,  after  turning  back 
the  conjunctiva,  have  also  been  recommended,  and  are 
worth  trial. 

(2  )  Sclero-keratitis and  sclero-iritis  ("scrofulous sclero- 
titis," "anterior choroiditis").  A  more  deeply-seated,  very 
persistent,  or  relapsing,  subacute  inflammation,  character- 
ized by  congestion  of  a  violet  tint  (deep  scleral  congestion, 
p.  55),  abruptly  limited  to  the  ciliary  zone,  and  affecting 
some  parts  of  the  zone  more  than  others  (tendency  to 
patchiness).  Early  in  the  case  there  is  a  slight  degree  of 
bulging  of  the  affected  part,  due  partly  to  thickening ; 
whilst  patches  of  cloudy  opacity,  which  may  or  may  not 
ulcerate,  appear  in  the  cornea  close  to,  and  often  continuous 
with,  its  margin ;  iritis  generally  occurs  later ;  pain  and 
photophobia  are  often  severe.  After  a  varying  interval, 
always  weeks,  more  often  months,  the  symptoms  recede ; 
at  the  focus  of  greatest  congestion,  or  it  may  be  around 
the  entire  zone,  the  sclerotic  is  left  of  a  dusky  color,  some- 
times interspersed  with  little  yellowish  patches,  and  per- 
manent haziness  of  the  most  affected  parts  of  the  cornea 
remains.  The  disease  is  almost  certain  to  relapse  sooner 
or  later;  or  a  succession  of  fresh  inflammatory  foci  follow 
each  other  without  any  intervals  of  real  recovery,  the 
whole  process  extending  over  months  or  years.  After  each 
attack  more  haze  of  cornea  and  fresh  iritic  adhesions  are 


DISEASES     OF     THE    CILIARY     REGION.        167 

left.  The  sclerotic,  in  bad  cases  of  some  years'  standing, 
is  much  stained,  and  may  become  bulged  (ciliary  or  ante- 
rior staphyloma),  and  the  cornea  becomes  more  opaque  and 
altered  in  curve ;  the  eye  is  then  useless,  though  seldom 
liable  to  further  active  symptoms. 

The  characteristic  appearance  of  an  eye  which  has  been 
moderately  affected  is  the  dusky  color  of  the  sclerotic  and 
the  irregular,  patchy  opacities  in  the  cornea  (Fig.  60),  which 

Fig.  60. 


Relapsing  sclero-keratitis.     (From  nature.) 

are  often  continuous  with  the  sclerotic.  The  disease  does 
not  occur  in  children,  nor  does  it  begin  late  in  life ;  most  of 
the  patients  are  young  or  middle-aged  adults,  and,  unlike 
the  former  variety,  most  are  women.  It  is  not  associated 
with  any  special  diathesis  or  dyscrasia,  but  generally  goes 
along  with  a  feeble  circulation  and  liability  to  "catch 
cold  ;''  in  some  cases  there  is  a  definite  family  history  of 
scrofula  or  of  phthisis.  Predisposed  persons  are  more  likely 
to  suffer  in  cold  weather,  or  after  change  to  a  colder  or 
damper  climate,  or  after  any  cause  of  exhaustion,  such  as 
suckling. 

Treatment  is  at  best  but  palliative.  Local  stimulation 
by  yellow  ointment  or  calomel  is  very  useful  in  some  cases, 
particularly  in  those  which  verge  toward  the  phlyctenular 
type.     In  the  early  stages,  especially  when  the  congestion 


168        DISEASES    OF     THE    CILIARY    REGION. 

is  v^ery  violent  and  altogether  subconjunctival,  atropine 
often  gives  relief,  and  it  is,  of  course,  useful  for  the  iritis. 
Repeated  blistering  is  also  to  be  tried,  though  not  all  cases 
are  benefited  by  it.  I  have  not  seen  much  benefit  from 
setons.  Warm,  dry  applications  to  the  lids  are,  as  a  rule, 
better  than  cold.  Mercury,  in  small  and  long-continued 
doses,  is  certainly  valuable  when  the  patient  is  not  anaemic 
and  feeble,  but  it  is  to  be  combined  with  cod-liver  oil  and 
iron.  Protection  from  cold  and  bright  light  by  "goggles" 
is  a  very  important  measure,  both  during  the  attacks  and 
in  the  intervals  between  them.  There  is  no  rule  as  to  sym- 
metry ;  both  eyes  often  suffer  sooner  or  later,  but  sometimes 
one  escapes  whilst  the  other  is  attacked  repeatedly.  Transi- 
tion forms  occur  between  this  disease  and  episcleritis. 

(3)  Cyclitis  with  disease  of  vitreous  and  keratitis 
punctata  (chronic  serous  irido-choroiditis,  "serous  iritis"). 
A  small  but  important  series  of  cases,  in  which  there 
is  congestion,  as  in  mild  iritis,  and  dulness  of  sight, 
but  usually  no  pain  or  photophobia.  Flocculi  are  found 
in  the  anterior  part  of  the  vitreous  or  numerous  small  dots 
of  deposit  are  seen  on  the  posterior  surface  of  the  cornea, 
keratitis  punctata,  Fig.  54  ;  the  anterior  chamber  is  often 
too  deep,  and  insidious  iritis  often  follows.  Patches  of  recent 
choroiditis  (Chap.  XII.)  are  sometimes  to  be  seen  at  the 
fundus.  In  bad  cases  buff-colored  masses  of  deposit  form 
in  the  lower  part  of  the  angle  between  iris  and  cornea ;  or 
distinct  nodules  may  be  present  on  the  iris  near  its  peri- 
phery, but  not,  as  in  syphilitic  iritis,  at  the  pupillary  border. 
Persistence,  variability,  and  liability  to  relapse  are  almost 
as  marked  here  as  in  other  members  of  the  cyclitic  group. 
The  tension  is  often  slightly  augmented  at  the  beginning, 
but  usually  becomes  normal  again.  Sometimes,  however, 
the  eye  passes  into  a  permanent  state  of  chronic  glaucoma,^ 

I  Perhaps  from  blocking  of  the  ligamentum  pectinatum  with  cells. 


DISEASES    OF     THE    CILIARY     REGION.         169 

without  the  intervention  of  plastic  iritis  (see  Glaucoma)  ; 
but  usually  the  final  condition  in  bad  eases  depends  on  the 
extent  of  the  iritic  adhesions,  for  when  the  synechiae  are 
numerous  and  tough,  and  the  iris  is  much  altered  in 
structure,  or  the  pupil  blocked  by  exudation,  secondary 
glaucoma  is  likely  to  arise  from  imprisonment  of  fluid 
behind  the  iris.  Fig.  59.  When  seen  quite  early  the  diag- 
nosis will  probably  be  "serous  iritis"  or  "ciliary  conges- 
tion," unless  the  eye  be  carefully  examined;  for  the  pupil 
is  generally  free  in  all  parts,  or  shows,  at  most,  one  or  two 
adhesions  after  atropine  has  been  used.  In  a  few  cases  the 
punctate  deposits  on  the  back  of  the  cornea  constitute 
almost  the  only  objective  change  (simple  keratitis  punc- 
tata), but  these  are  rare.  The  refraction  sometimes  becomes 
temporarily  myopic  in  serous  iritis. 

The  cases  occur  in  adolescents  or  young  adults,  and  the 
disease  is  often  sooner  or  later  symmetrical.  Many  mild 
cases  recover  perfectly,  and  in  most  others  the  final  result 
is  satisfactory.  In  respect  to  cause,  there  is  strong  reason 
to  believe  that  many  of  these  cases  are  the  result  of  gout 
in  a  previous  generation,  the  patient  himself  never  having 
had  the  disease.  The  disease  seems  often  to  be  excited  in 
predisposed  persons  by  prolonged  overwork  or  anxiety, 
combined  with  underfeeding,  or  defective  assimilation  ; 
the  patients  often  describe  themselves  as  delicate ;  some  are 
phthisical.  On  the  other  hand,  in  some  of  the  worst  cases, 
leading  to  secondary  cataract,  and  ultimately  to  shrinking 
of  the  eyes,  the  patient  appears  to  be,  from  first  to  last,  in 
good  health,  and  free  from  any  ascertainable  morbid  dia- 
thesis. 

In  the  treatment,  prolonged  rest  of  the  eyes  is  important. 
Atropine  is  usually  necessary,  but  if  there  be  increase  of 
tension  its  effect  must  be  carefully  watched,  and  in  cases 
where  there  are  no  iritic  adhesions  eserine  may  have  to  be 
substituted.      If  the  increase  of  tension  keeps  up,  an4 


170        DISEASES     OF     THE     CILIARY     REGION. 

Fccnis  to  be  damaging  the  sight,  iridocton^y  is  nccessory. 
Small  doses  of  iodide  of  potassium  and  mercury  appear  to 
he  useful  in  the  earlier  stages,  given  with  proper  precau- 
tions, and  accompanied  by  iron  and  cod-liver  oil.  Change 
of  climate  would  probably  often  be  very  beneficial.  In 
the  worst  cases,  where  the  changes  are  like  those  resulting 
from  sympathetic  ophthalmitis,  no  treatment  seems  to 
have  any  effect. 

Cases  of  acute  inflammation  are  occasionally  seen  in 
which  most  of  the  symptoms  resemble  those  of  acute  iritis, 
but  with  the  iris  so  little  affected  that  it  is  evidently  not  the 
headquarters  of  the  morbid  action.  The  tension  may  be 
much  reduced,  whilst  repeated  and  rapid  variations,  both 
in  sight  and  objective  symptoms,  occur.  To  some  of  these 
the  term  idiopathic  phthisis  hiilbi  has  been  applied.  Again, 
some  cases  of  syphilitic  inflammation,  which  are  classed 
as  syphilitic  "  iritis,"  might  more  correctly  be  called 
"  cyclitis."  In  some  cases  of  heredito-syphilitic  keratitis 
there  is  much  cyclitic  complication,  and  these  are  always 
difficult  to  treat. 

Plastic  inflammation  of  the  ciliary  body,  following 
injury,  traumatic  ileitis  or  irido-cyclitis,  is  the  usual  start- 
ing-point of  the  changes  which  set  up  sympathetic  inflam- 
mation of  the  fellow-eye;  the  tension  is  often  lowered,  and 
the  symptoms  subacute  The  onset  oi purulent  traumatic 
cyclitis  panophthalmitis  is  signalized  by  congestion,  pain, 
chemosis,  and  swelling  of  the  lids,  and  the  appearance  of 
opacity  at  the  w^ound.  The  inflammation  quickly  spreads 
to  the  iris,  ciliary  body,  and  vitreous,  and  then  to  the  cap- 
sule of  Tenon  and  the  muscles,  so  that  the  eye  becomes 
glued  to  the  surrounding  parts  and  fixed.  If  the  lens  be 
transparent  a  yellow  or  greenish  reflection  is,  after  a  few 
days,  sometimes  seen  behind  it,  indicating  the  presence  of' 
pus  in  the  vitreous  humor;  but  usually  the  cornea  and 
aqueous  are  too  turbid,  even  should  the  lens  be  clear,  to 


SYMPATHETIC    IRRITATION.  171 

allow  deep  inspection.  Suppurative  panophthalmitis  occa- 
sionally sets  in  acutely  and  without  apparent  cause  in  eyes 
which  have  long  been  blind  from  corneal  disease  or  from 
glaucoma.  It  may  also  occur  in  pyaemia  (Chap.  XXIII). 
See  also  Pseudo-glioma. 

Sympathetic   Irritation   and   Sympathetic 
Ophthalmitis. 

Certain  morbid  changes  in  one  eye  may  set  up  either 
functional  disturbance  or  destructive  inflammation  in  its 
fellow.  The  term  sympathetic  ir^ritation  is  given  to  the 
former,  and  sympathetic  ophthalmitis,  or  ophthalmia,  to  the 
latter.  Though  these  conditions  may  be  combined,  they 
more  often  occur  separately,  and  it  is  very  important  to 
distinguish  between  them. 

Although  at  present  the  exact  nature  of  the  changes 
which  precede  sympathetic  inflammation  is  unknown,  and 
their  path  has  not  been  fully  traced  out,  we  are  sure  (1) 
that  the  changes  start  from  the  region  most  richly  supplied 
with  vessels  and  nerves,  viz. :  the  ciliary  body  and  iris  ;  (2) 
that  the  first  changes  recognized  by  the  surgeon  in  the 
sympathizing  eye  are  generally  in  the  same  structures  ;  (3) 
that  the  exciting  eye  has  nearly  always  been  wounded,  and 
in  its  anterior  part,  and  that  plastic  inflammation  of  its 
uveal  tract  is  always  present ;  (4)  that  inflammatory 
changes  have  in  some  cases  been  found  in  the  ciliary 
nerves,  and  in  the  coverings  of  the  optic  nerve,  of  the 
exciting  eye. 

Within  the  last  few  years  the  hypothesis  of  transmission 
along  the  ciliary  nerves,  which  had  many  adherents,  has 
been  almost  given  up  in  favor  of  the  theory  of  infection. 
Deutschmann  has  shown  (1882-84)  that  the  introduction 
of  certain  septic  organisms  into  the  interior  of  the  eyeball, 
in  rabbits,  is  followed  by  acute  inflammatory  changes  in  the 
other  eye,  and  Giff'ord  (1886),  and  others  more  recently, 


172        DISEASES    OF    THE    CILIARY    REGION. 

have  obtained  results  which  tend  to  confirm  the  infection 
theory.  Most  of  Deutschmann's  subjects  died  in  a  few- 
days,  and  though  in  many  of  them  the  ocular  changes  were 
those  of  inflammation  traceable  along  the  optic  nerve- 
sheaths  of  the  "exciting"  eye,  byway  of  the  chiasma,  and 
down  the  optic  nerve  to  the  optic  disc  of  the  "  sympathiser," 
still  in  one  or  two  the  morbid  process  had  spread  to  the 
vitreous  and  uveal  coat.  Berlin'  had  previously  suggested 
that  the  second  eye  was  infected  by  a  special  organism 
w^hich  could  flourish  only  in  the  eye-tissues,  and  which  was 
carried  by  the  blood  from  the  first  eye ;  and  Hutchinson' 
afterwards  independently  propounded  a  nearly  identical 
view.  Though  there  are  diflBculties  to  be  explained  and 
gaps  to  be  filled  in  our  knowledge  before  the  infection 
theory  in  any  form  can  be  accepted,  yet  at  the  present  time 
it  claims  more  and  stronger  adherents  than  any  other ;  and 
the  difficulties  are,  perhaps,  not  greater  than  for  any  other 
theory. 

In  almost  every  case  sympathetic  inflammation  is  set  up 
by  a  perforating  wound,  either  accidental  or  operative,  in 
the  ciliary  region  of  the  other  eye,  i.  e.,  within  a  zone, 
nearly  a  quarter  of  an  inch  wide,  surrounding  the  cornea. 
The  risk  attending  a  wound  in  this  "  dangerous  zone"  is 
increased  if  it  be  lacerated,  or  heal  slowiy,  or  if  the  iris  or 
ciliary  body  be  engaged  between  the  lips  of  the  sclerotic, 
or  if  the  eye  contain  a  foreign  body  ;  under  all  conditions, 
indeed,  which  make  the  occurrence  of  plastic  or  purulent 
irido-cyclitis  probable.  Sympathetic  inflammation  may 
also  be  set  up  by  a  foreign  body  lodged  in  the  eye,  w^hether 
the  wound  be  in  the  ciliary  region  or  not ;  by  an  eye  con- 
taining a  tumor,  perhaps  even  if  the  eye  have  not  been 
perforated  by  operation  or  ulceration  ;  by  a  purely  corneal 
wound,  or  a  perforating  ulcer,  if  complicated  by  adhesion 
of  the  iris,  with  dragging  on  the  ciliary  body. 

1  Berlin,  1880.  2  Hutchinson,  1885. 


SYMPATHETIC    IRRITATION.  173 

Symptoms   in  the   exciting    eye The    exciting  eye, 

when  it  is  causing  sympathetic  tmYahow,  generally  shows 
ciliaiy  congestion  and  photophobia,  and  often  sufifers  neu- 
ralgic pain.  In  an  eye  which  is  causing  sympathetic  in- 
Jiammation,  obvious  iritis,  often  with  lowered  tension,  is 
usually  present ;  but  the  iritis  is  often  painless  and  without 
noticeable  congestion,  and  thus  may  easily  be  overlooked  ; 
it  is  especially  important  to  remember  that  the  exciting 
eye,  though  its  sight  is  always  damaged,  need  not  be  blind, 
and  that  under  certain  circumstances  it  may  in  the  end  be 
the  better  eye  of  the  two. 

Symptoms  in  the  sympathizing  eye.  a.  Sympathetic  irri- 
tation.— The  eye  is,  in  common  speech,  "  weak  "  or  "  irrita- 
ble." It  is  intolerant  of  light  and  easily  flushes  and  waters 
if  exposed  to  bright  light,  or  if  much  used  ;  the  accommo- 
dation is  weakened  or  irritable,  so  that  continued  vision  for 
near  objects  is  painful,  or  even  impossible  ;  and  the  ciliary 
muscle  seems  liable  to  give  way  for  a  short  time,  the  patient 
complaining  that  near  objects  now  and  then  suddenly  be- 
come misty  for  a  while.  Neuralgic  pains,  referred  to  the  eye 
and  side  of  the  head,  are  also  common.  Temporary  dark- 
ening of  sight,  indicating  suspension  of  retinal  function,  and 
subjective  sensations  of  colored  spots,  clouds,  etc.,  occur  in 
certain  cases.  Such  attacks  may  occur  again  and  again  in 
varying  severity,  lasting  for  days  or  weeks,  and  finally 
ceasing  without  ever  passing  on  to  structural  change. 
Sympathetic  irritation  is  always  and,  as  a  rule,  promptly, 
cured  by  removal  of  the  exciting  eye  ;  but  occasionally  the 
symptoms  persist  for  some  time  afterwards.  A  condition 
which  cannot  be  distinguished  from  hysterical  blindness  is 
sometimes  seen  in  the  "sympathizing"  eye,  but  the  term 
sympathetic  irritation  does  not  then  seem  suitable.^ 

^  Mr.  Gunn  tells  me  that  he  has  noticed  that  marked  oscillation  of 
the  iris  often  occurs  when  sympathetic  irritation  is  about  to  give  place 
to  inflammation. 


174        DISEASES    OF     THE     CILIARY     REGION. 

b.  Sympathetic  in Jlammation  {Ophthalmitis). — The  dis- 
ease may  arise  out  of  an  attack  of  "  irritation,"  but  more 
commonly  it  sets  in  without  any  such  warning  It  may  be 
acute  and  severe,  or  so  insidious  as  to  escape  the  notice  of 
the  patient  until  well  advanced.  It  is  in  nearly  all  cases  a 
prolonged  and  a  recurring  disease  ;  when  once  started  it  is 
self-maintaining,  and  its  course  usually  extends  over  many 
months,  oreven  a  year  or  two.  In  mild  casesa  good  recov- 
ery eventually  takes  place,  but  in  a  large  majority  the  eye 
becomes  blind.  The  disease  usually  takes  the  form  of  a 
plastic  irido-cyclitis  or  irido-choroiditis  with  exudation 
from  the  entire  posterior  surface  of  the  iris,  leading  to 
total  posterior  synechia.  Its  chief  early  peculiarities  are 
great  liability  to  dotted  deposits  on  the  back  of  the  cornea, 
clouding  of  the  vitreous  by  floating  opacities,  and  often 
neuro-retinitis;  there  is  a  dusky  ciliary  congestion  with 
marked  engorgement  of  the  large  vessels  which  perforate  the 
sclerotic  in  the  ciliary  region.  In  acute  and  severe  cases 
the  congestion  is  intense,  there  is  severe  pain,  photophobia, 
and  tenderness  on  pressure,  and  the  iris,  besides  being  thick, 
is  changed  in  color  to  a  peculiar  buff  or  yellow^ish  brown, 
and  shows  numerous  enlarged  bloodvessels.  Attacks  of  in- 
tense neuralgia  of  the  fifth  nerve  characterize  some  cases. 
In  cases  of  all  degrees  the  tension  is  often  increased,  the 
eyebecoming  decidedly  glaucomatous  for  a  longer  or  shorter 
time.  Many  dotted  opacities  appear  in  the  lens,  which 
afterwards  becomes  completely  cataractous  and  in  some 
cases  is  finally  quite  absorbed.  In  the  worst  cases  the  eye 
finally  shrinks,  but  in  many  it  remains  glaucomatous  with 
total  posterior  synechia,  corneal  haze,  and  more  or  less 
ciliary  staphyloma.  In  the  mildest  cases,  the  so-called 
"serous"  form,  the  disease  never  goes  beyond  a  chronic 
iritis  with  punctate  keratitis  and  disease  of  the  vitreous, 
with  which  neuro-retinitis  often,  perhaps  always,  coexists. 

Sympathetic  ophthalmitis  generally  begins  between  six 


SYMPATHETIC     OPHTHALMITIS.  175 

weeks  and  about  three  months  after  the  injury  to  the  ex- 
citing eye  ;  very  seldom  sooner  than  three  weeks,  i^e.,  not 
until  time  has  elapsed  for  well-marked  inflammatory 
changes  to  occur  at  the  seat  of  injury.  On  the  other 
hand,  the  disease  may  set  in  at  any  length  of  time,  even 
many  years,  after  the  lesion  of  the  exciting  eye.  It  occurs 
at  all  ages.  Distinct  inflammatory  changes  are  probably 
always  present  in  the  exciting  eye  ;  but,  as  already  stated, 
these  may  be  very  slight  and  difficult  of  detection.  When 
carefully  observed,  these  changes  are  found  to  precede  by 
some  days,  if  not  longer,  the  onset  of  structural  disease  in 
the  sympathizing  eye,  the  morbid  process  apparently  taking 
some  time  to  travel  from  one  eye  to  the  other. 

Treatment. — By  far  the  most  important  measure  refers 
to  prevention.  When  once  sympathetic  inflammation  has 
begun  we  can  do  little  to  modify  its  course.  The  clear  re- 
cognition of  this  fact  leads  us  to  advise  the  excision^  of 
every  eye  which  is  at  the  same  time  useless  and  liable  to 
cause  sympathetic  mischief,  i.  e.,  of  all  eyes  which  are 
blind  from  injury  or  destructive  corneal  disease;  and  to 
give  this  advice  most  urgently  when  the  blind  eye  is 
already  tender  or  irritable,  or  is  liable  to  become  so,  when 
it  has  been  lost  by  wound,  and  when  it  is  probable  that  it 
may  contain  a  foreign  body.  Any  lost  eye  in  which  there 
are  signs  of  past  iritis,  even  if  there  be  no  history  of  injury, 
is  best  removed,  especially  if  shrunken.  But  much  judg- 
ment is  needed  if  the  damaged  eye,  though  irritable  and 
likely  to  cause  mischief,  still  retains  more  or  less  sight. 
Every  attention  must  then  be  paid  to  the  exact  position  of 
the  wound,  the  evidence  as  to  its  depth,  the  evidence  of 

1  Feeling  doubtful  whether  either  abscission  or  op  tico-ciliary  neuro_ 
tomy  confers  as  great  safety  from  sympathetic  disease  as  does  excision, 
I  have  not  performed  those  operations.  The  more  newly  revived  evis- 
ceration has  not  yet  been  performed  often  enough  for  trustworthy  con- 
clusions to  be  drawn  on  this  point. 


176        DISEASES     OF     THE     CILIARY     REGION. 

hemorrhage,  and  especially  to  the  condition  of  the  lens, 
and  to  the  presence  of  the  yellowish  haziness  behind  the 
lens  which  indicates  lymph  or  pus  in  the  vitreous.  The 
date  of  the  injury  and  the  condition  of  the  wound,  whether 
healed  by  immediate  union,  or  with  scarring,  puckering,  or 
flattening,  are  very  important  points.  Irritation  of  the 
fellow-eye  may  set  in  a  few  days  after  the  injury ;  but  since 
inflammation  very  seldom  begins  sooner  than  two  or  three 
weeks,  we  may,  if  we  see  the  case  early,  watch  it  for  a  little 
time.  Complete  and  prolonged  rest  in  a  darkened  room  is 
a  very  important  element  in  the  prevention  of  sympathetic 
irritation  and  inflammation,  and  should  always  be  insisted 
on  when  we  are  trying  to  save  an  injured  eye.  In  rare 
cases  sympathetic  inflammation  sets  in  a/ifer  the  removal 
of  the  exciting  eye,  even  after  an  interval  of  several  weeks, 
a  contingency  which  emphasises  the  importance  of  excising 
every  condemned  eye  at  the  earliest  possible  moment. 

When  sympathetic  ophthalmitis  has  set  in  we  can  do  com- 
paratively little. 

A.  The  exciting  eye,  if  quite  blind  or  so  seriously  dam- 
aged as  to  be  for  practical  purposes  certainly  useless,  is  to  be 
excised  at  once,  though  the  evidence  of  benefit  from  this 
course  is  slender.  But  it  is  not  to  be  removed  if  there  is 
reason  to  hope  for  restoration  of  useful  sight  in  it;  if  there 
is  simply  a  moderate  degree  of  subacute  iritis,  with  or  with- 
out traumatic  cataract,  and  with  sight  proportionate  to  the 
state  of  the  lens,  the  eye  is  to  be  carefully  treated,  since  it 
may  very  probably  in  the  end  be  the  better  of  the  two. 

B.  The  sympathizing  eye. — The  important  measures  are : 
(1)  atropine,  used  very  often,  as  for  acute  iritis;  (2)  abso- 
lute rest  and  exclusion  of  light  by  residence  in  a  dark  room 
and  with  a  black  bandage  over  both  eyes;  (3)  repeated 
leeching  if  the  symptoms  are  severe,  or  counter-irritation 
by  blisters  or  by  a  seton  in  chronic  cases.  (4)  Mercury  is 
believed  by  some  to  be  beneficial.     Quinine  is  sometimes 


SYMPATHETIC     OPHTHALMITIS.  177 

given.  (5)  As  a  rule  no  operation  is  permissible  whilst 
the  disease  is  still  active,  since  iridectomy,  performed  whilst 
there  are  active  symptoms,  is  followed  by  closure  of  the 
gap  with  fresh  lymph.  Operations  in  severe  cases  which 
have  become  quiet  are  seldom  of  use,  the  eye  being  gen- 
erally then  past  recovery. 

The  prognosis  is,  as  will  be  gathered,  very  grave  ;  even 
in  the  mildest  cases,  when  seen  quite  early,  we  must  be  very 
cautious,  for  the  disease  often  slowly  progresses  for  many 
months. 


8* 


CHAPTER   X. 


INJURIES    OF    THE    EYEBALL. 


A  CLEAR  distinction  is  to  be  made  between  contusion 
and  concussion  injuries,  and  wounds  of  the  eyeball. 

(1)  Contusion  and  concussion  injuries. — RuxAure  of  the 
eyeball  is  commonly  the  result  of  severe  direct  blows.  The 
rent  is  nearly  always  in  the  sclerotic,  either  a  little  behind 
or  close  to  the  corneal  margin,  with  which  it  is  concentric  ; 
the  cornea  itself  is  but  seldom  rent  by  a  blow.  The  rup- 
ture is  usually  large,  involves  all  the  tunics,  and  is  followed 
by  immediate  hemorrhage  between  the  retinal  and  choroid 
and  into  the  vitreous  and  anterior  chambers  ;  the  lens  and 
some  of  the  vitreous  often  escape  ;  sight  is  usually  reduced 
to  perception  of  light  or  of  large  objects.  The  conjunc- 
tiva, however,  often  escapes  untorn,  and  in  such  a  case  if 
the  lens  pass  through  the  rent  in  the  sclerotic,  it  will  be 
held  down  by  the  conjunctiva  and  form  a  prominent, 
rounded,  translucent  swelling  over  the  rupture.  The  diag- 
nosis of  rupture  is  generally  easy,  even  if  the  rent  be  more 
or  less  concealed.  The  eyeball  often  shrinks  ;  but  occa- 
sionally it  recovers  with  useful  vision.  Immediate  excision 
is  generally  best  when  the  wound  is  "  compound  ;"  but  if 
the  conjunctiva  be  not  torn,  and  occasionally  even  when  it 
is,  we  should  wait  a  few  days  until  the  disappearance  of 
the  blood  from  the  anterior  chamber  allows  the  deeper 
parts  to  be  seen.  The  treatment  is  the  same  as  for  wounds 
of  the  eye.  When  the  lens  is  lying  beneath  the  conjunctiva 
it  should  be  removed  when  the  scleral  wound  has  healed, 
if  we  decide  to  save  the  eve. 


INJURIES     OF     THE     EYEBALL.  179 

It  may  be  here  mentioned  that  copious  hemorrhage,  ac- 
companied by  severe  pain,  sometimes  occurs  between  the 
choroid  and  sclerotic  as  the  result  of  sudden  diminution  of 
tension,  either  by  an  operation,  such  as  extraction  of  cata- 
ract or  iridectomy,  or  by  a  glancing  wound  of  the  cornea. 
Eyes  in  which  this  occurs  are  for  most  part  already  unsound 
and  often  glaucomatous. 

Blows  oftencsiuseinternaldamagewithout  rupture  of  tfie 
hard  coats  of  the  eye.  The  iris  may  be  torn  from  its  ciliary 
attachment  {coredialyais),  so  that  two  pupils  are  formed, 

Fig.  61. 


Separation  of  iris  following-  a  blow. 

Fig.  61,  or  the  lens  may  be  loosened  or  displaced  by  partial 
rupture  of  its  suspensory  ligament,  so  that  the  iris,  having 
lost  its  support,  will  shake  about  with  every  movement 
{tremulous  iris).  Such  lesions  are  likely  to  be  obscured  for 
a  time  by  bleeding  into  the  anterior  chamber  and  into  the 
vitreous.  The  lens  often  becomes  opaque  afterward.  De- 
tachment of  the  retina  is  often  found  after  severe  blows, 
which  have  caused  hemorrhage  into  the  vitreous.  Blows 
on  the  front  of  the  eye  may  cause  rupture  of  the  chor^oid  or 
hemorrhage  from  choroidal  or  retinal  vessels.  These 
changes  are  found  at  the  central  part  of  the  fundus,  and 
if  the  yellow  spot  is  involved  visual  acuteness  is  much 
damaged.  The  rents  in  the  choroid  appear  after  the  blood 
has  cleared  up,  as  lines  or  narrow  bands  of  atrophy  bor- 
dered by  pigment,  and  often  slightly  curved  toward  the 


180  INJURIES     OF     THE     EYEBALL. 

disc,  Fig.  74.  Hemorrhages  from  the  choroidal  vessels 
without  rupture  of  the  choroid  usually  leave  some  residual 
pigment  after  absorption.  In  an  eye  predisposed  to  detach- 
ment of  retina,  a  blow  will  sometimes  determine  its  occur- 
rence, ParalymHofthe  iris  and  ciliary  mvscle,  with  partial 
and  often  irregular  dilatation  of  the  pupil,  are  often  the 
sole  results  of  a  blow  on  the  eye ;  the  defect  of  sight  can 
be  remedied  by  a  convex  lens.  Complete  restitution  is 
moderately  common  ;  the  ciliary  muscle  recovers  before 
the  iris.  Partial  dilatation  or  imperfection  of  the  pupil 
after  a  blow  is  sometimes  dependent  on  a  rupture  of  the 
sphincter,  one  or  more  notches  in  the  pupillary  border  of 
the  iris  indicating  the  seat  of  the  lesion  or  lesions.  For 
Traumatic  Iritis  see  p.  159. 

Great  defect  of  sight  following  a  blow,  and  neither  rem- 
edied by  glasses  nor  accounted  for  by  blood  in  the  anterior 
chamber,  will  generally  mean  copious  hemorrhage  into 
the  vitreous,  with  one  or  another  of  the  changes  just  men- 
tioned in  the  retina  and  choroid.  The  red  blood  may  some- 
times be  seen  by  focal  light,  but  often  its  presence  can  only 
be  inferred  from  the  opaque  state  of  the  vitreous.  Proba- 
bly in  most  of  these  cases  the  blood  comes  from  the  large 
veins  of  the  ciliary  body,  but  sometimes  from  the  vessels 
of  the  choroid  or  retina.  There  may  be  no  external  ecchy- 
raosis.  The  tension  of  the  globe  is  to  be  noted  ;  it  is  not 
often  increased  unless  inflammation  have  set  in,  or  the  eye 
were  previously  glaucomatous,  and  in  some  cases  it  is  below 
par.  The  prognosis  should  be  very  guarded  whenever  there 
is  reason  to  think,  from  the  opaque  state  of  the  parts  behind 
the  lens,  that  much  bleeding  has  taken  place,  or  that  the 
retina  is  detached,  or  when  the  iris  is  tremulous  or  partly 
detached,  or  if  any  rupture  of  the  choroid  can  be  made 
out.  Blood  in  the  anterior  chamber  is  often  completely 
absorbed  in  a  day  or  two,  or  even  sometimes  in  a  few 
hours  ;  but  in  the  vitreous  humor  absorption,  though  rapid, 


INJURIES     OF     THE     EYEBALL.  181 

is  less  complete,  and  permanent  opacities  are  often  left. 
The  use  of  atropine,  the  frequent  application,  during  the 
first  twenty-four  hours,  of  iced  water,  or  of  an  evaporating 
lotion  to  the  lids,  and  occasional  leeching  if  there  be  in- 
flammatory symptoms,  will  do  all  that  is  possible  for  the 
first  week  or  two  after  a  severe  blow  with  internal  hemor- 
rhage. If  the  lens  be  loosened  it  may  at  any  time  act  as 
an  irritating  foreign  body,  or  set  up  a  glaucomatous  in- 
flammation :  Dislocation  of  Lens,  p.  208.  Now  and  then 
optic  neuritis  occurs  in  the  injured  eye  as  the  immediate 
effect  of  the  blow.  Hemorrhage  behind  the  choroid  is  be- 
lieved to  account  for  certain  well-known  cases  in  which, 
after  a  blow,  there  is  defect  of  sight  without  a  visible 
change,  or  with  localized  temporary  haze  of  retina 
{''commotio  retinse''-).  Temporary  myopia  or  astigmatism 
may  also  follow  a  blow  on  the  eye  ;  they  depend  on  altered 
curvature  of  the  lens,  and  are  sometimes  entirely  removed 
by  paralyzing  the  ciliary  muscle  with  atropine.  See  also 
Hysterical  Amblyopia, 

(2)  Wounds. — A.  Superficial  abrasions  of  the  cornea 
cause  much  pain,  with  watering,  photophobia,  and  ciliary 
congestion.  They  are  frequently  due  to  a  scratch  by  a 
finger-nail  of  a  baby  at  the  breast.  The  abraded  surface 
is  often  very  small  and  shows  no  opacity  ;  it  is  detected  by 
watching  the  reflection  of  a  window  from  the  cornea,  whilst 
the  patient  slowly  moves  the  eye.  Now  and  then  the  symp- 
toms return  after  a  long  interval  of  cure.  Many,  if  not  all 
of  the  cases  of  relapsing  bullje  of  the  cornea  seem  to  have 
originated  in  a  slight  superficial  injury. 

Minute  fragments  of  metal  or  stone  flying  from  tools, 
etc.,  often  partly  imbed  themselves  in  the  cornea, /o7'e?'y^i 
body  on  the  cornea,  and  give  rise  to  varying  degrees  of  irri- 
tability and  pain.  The  fragment  soon  becomes  surrounded 
by  a  hazy  zone  of  infiltration,  but  it  remains  easily  visible 
unless  it  be  very  small  or  covered  by  mucus  or  epithelium. 


182  INJURIES     OF     THE     EYEBALL. 

When  in  douht  always  examine  tlie  cornea  by  focal  light 
with  magnifying  power. 

The  pupil  is  often  smaller  than  its  fellow,  and  the  color 
of  the  iris  altered,  in  cases  of  superficial  injur}^  to  the 
cornea,  indicating  congestion  of  the  iris.  Actual  iritis 
sometimes  occurs,  but  not  unless  the  corneal  wound  inflame. 

Treatment. — (For  removal  of  foreign  bodies,  see  Ope- 
rations.) After  surface  injuries  a  drop  of  castor  oil  may  be 
applied,  and  the  eye  kept  closed  for  the  day  with  a  pad 
of  wadding  and  a  bandage.  Atropine  is  required  if  there 
be  much  irritation  or  threatened  iritis.  If  hypopyon  ap- 
pear the  case  becomes  one  of  hypopyon  ulcer. 

Foreign  bodies  often  adhere  to  the  inner  surface  of  the 
upper  lid  ;  whenever  a  patient  states  that  he  has  "  some- 
thing in  his  eye"  and  nothing  can  be  found  on  the  cornea, 
the  upper  lid  must  be  everted  and  examined. 

Large  bodies  sometimes  pass  far  back  into  the  upper  or 
lower  conjunctival  sulcus  and  lie  hidden  for  weeks  or  months, 
causing  only  local  inflammation  and  some  thickening  of  the 
conjunctiva.  Search  must  be  made,  if  needful,  with  a  small 
scoop  or  probe  whenever  the  suspicion  arises.    (See  Orbit.) 

B.  Bi(7V2s,  scalds,  and  injuries  by  caustics,  etc. — The 
conjunctiva  and  cornea  are  often  damaged  by  splashes  of 
molten  lead,  or  by  strong  alkalies  or  acids,  of  which  lime, 
either  quick  or  freshly  slaked,  is  the  commonest.  The  eye- 
ball is  not  often  scalded,  the  lids  closing  quickly  enough  to 
prevent  the  entrance  of  steam  or  hot  water.  As  in  no  such 
cases  is  the  full  effect  apparent  for  some  daj^s,  a  cautious 
opinion  should  be  given  in  the  early  stages. 

The  effects  of  such  accidents  are  manifested  by  (1)  in- 
flammation of  the  cornea  passing  into  suppurative  keratitis 
with  hypopyon,  in  bad  cases;  (2)  scarring  and  shortening 
of  the  conjunctiva,  and  in  bad  cases  adhesion  of  its  palbe- 
bral  and  ocular  surfaces,  symhlepharon. 

The  most  superficial  burns  whiten  and  dry  the  surface 


INJURIES    OF     THE    EYEBALL.  183 

and  in  a  few  hours  the  epithelium  is  shed.  This  is  shown 
on  the  cornea  by  a  sharply  outlined,  slightly  depressed 
area.  The  surface  is  clear  if  the  damage  be  quite  super- 
ficial and  recent,  but  more  or  less  opalescent,  or  even  yel- 
lowish, if  the  case  be  a  few  days  old,  and  the  burn  be  deep 
enough  to  have  caused  destruction  or  inflammation  of  the 
true  corneal  tissue.  When  there  is  much  opacity  it  does 
not  completely  clear,  and  considerable  flattening  of  the 
cornea  and  neighboring  sclerotic  often  occurs  at  the  seat 
of  deep  and  extensive  burns.  The  conjunctival  whitening 
is  followed  by  mere  desquamation  and  vascular  reaction, 
or  by  ulceration  and  scarring,  according  to  the  depth  of 
the  damage. 

Treatment. — In  recent  cases,  seen  before  reaction  has 
begun,  a  drop  of  castor  oil  once  or  twice  a  day,  a  few 
leeches  to  the  temple,  and  the  use  of  a  cold  evaporating 
lotion,  or  of  iced  water,  will  sometimes  prevent  inflamma- 
tion. If  seen  immediately  after  the  accident,  the  conjunc- 
tival sac  is  to  be  carefully  searched  for  fragments,  or  washed 
with  very  weak  acid  or  alkaline  solution  if  a  liquid  caustic 
of  the  opposite  character  have  done  the  damage.  If  in- 
flammatory reaction  be  already  present,  treatment  by  com- 
press, hot  fomentations,  and  the  other  means  recommended 
for  suppurating  ulcers,  p.  138,  is  most  suitable.  There 
is  often  much  pain  and  chemosis.  (See  Operation  for 
Symblepharon.) 

c.  Penetrating  wounds  and  gunshot  injuries. — When  a 
patient  says  that  his  eye  is  wounded,  the  first  step  is  to 
examine  the  seat,  extent,  and  character  of  the  wound, 
ascertain  the  interval  since  the  injury,  and  test  the  sight 
of  the  eye  ;  the  next  to  make  out  all  we  can  about  the 
wounding  body,  and  especially  whether  any  fragment  has 
been  left  within  the  eyeball. 

Yery  large  foreign  bodies,  such  as  pieces  of  glass,  some- 
times lie  long  in  the  eye  without  causing  much  trouble. 


184  INJURIES    OF     THE     EYEBALL. 

the  large  wound  having  given  exit  to  the  contents  of  the 
globe,  and  been  followed  by  rapid  shrinking  without  in- 
flammation. 

Treatment. — Penetrating  wounds  are  least  serious 
when  they  implicate  the  cornea  alone,  or  the  sclerotic 
behind  the  ciliary  region,  i.  e.,  ^  inch  or  more  behind  the 
cornea.  Penetrating  wounds  of  the  cornea  without  injury 
to  the  iris  or  lens,  and  without  any  prolapse  of  iris,  are 
rare ;  they  generally  do  very  well,  and  if  the  case  be  not 
seen  until  one  or  two  days  after  the  injury,  the  wound  will 
often  have  healed  firmly  enough  to  retain  the  aqueous,  and 
it  may  be  difficult  to  decide  whether  the  whole  thickness 
of  the  cornea  have  been  penetrated  or  not.  Wounds  of 
the  sclerotic  seldom  unite  without  the  interposition  of  a 
layer  of  lymph  ;  when  seen  early  they  should,  if  gaping, 
clean,  and  uncomplicated  by  evidence  of  internal  injury, 
be  treated  by  the  insertion  of  fine  sutures,  which  should 
be  passed  only  through  the  conjunctiva,  followed  by  the 
use  of  ice. 

But  penetrating  wounds  are  usually  very  serious  to  the 
injured  eye  ;  the  iris  is  frequently  lacerated  and  included  in 
the  track  of  the  wound  ;  the  lens  is  punctured  and  becomes 
swollen  and  opaque  from  absorption  of  the  aqueous  humor, 
traumatic  cataract,  and  liable  in  its  swollen  state  to  press 
on  the  ciliary  processes  and  cause  grave  symptoms;  exten- 
sive bleeding  perhaps  takes  place  in  the  vitreous ;  within 
the  first  few  days  purulent  inflammation  may  destroy  the 
eye.  The  fellow-eye  is,  of  course,  often  in  danger  of  sym- 
pathetic inflammation.  Every  case  has  therefore  to  be 
judged  from  two  points  of  view,  the  damage  to  the  injured 
eye  and  the  risk  to  the  sound  one;  and  the  question 
whether  to  sacrifice  or  attempt  to  save  the  former,  is  some- 
times very  difficult  to  decide. 

( I. )  In  the  two  following  cases  the  eye  should  be  sacrificed 
at  once:   (1)  If  the  wound,  lying  wholly  or  partly  in  the 


INJURIES     OF     THE     EYEBALL.  185 

"dangerous  region"  be  so  large  and  so  complicated  with 
injury  to  deeper  parts  that  no  hope  of  useful  sight  remains. 
(2)  If,  even  though  the  wound  be  small,  it  lie  in  the  dan- 
gerous region,  and  have  already  set  up  severe  iritis  (pp.  159 
and  170). 

(II.)  There  is  a  large  class  of  cases  in  which  it  is  certain 
or  very  probable  that  the  eye  contains  a  foreign  body,  al- 
though the  injury  is  not  of  itself  fatal  to  sight  and  has  not 
as  yet  led  to  inflammation  or  to  shrinking  of  the  eye. 

The  first  question  then  is  whether  the  foreign  body  can 
be  seen,  the  second,  whether  or  not  it  is  steel  or  iron,  and 
therefore  possibly  removable  by  a  magnet.  A  foreign  body, 
if  lying  on  or  embedded  in  the  iris,  the  lens  being  intact, 
should  be  removed,  usually  with  the  portion  of  iris  to  which 
it  is  attached  ;  if  loose  in  the  anterior  chamber  its  removal 
may  be  difficult.  If  it  can  be  seen  embedded  in  the  lens 
and  the  condition  of  the  eye  be  otherwise  favorable,  a 
scoop  extraction  may  be  done  in  the  hope  of  removing  the 
fragment  with  the  lens  ;  or  the  lens  may  be  allowed,  or  by 
a  needle  operation  induced,  to  undergo  partial  absorption 
and  shrinking  so  as  to  enclose  the  foreign  body  more  firmly, 
and  when  subsequently  extracted  bring  it  away.  If  we 
are  certain  that  the  foreign  body  has  passed  into  the  vit- 
reous, whether  through  the  lens  or  not,  and  whether  by 
gunshot  or  not,  we  can  seldom  save  the  eye.  The  foreign 
body  can  in  such  a  case  seldom  be  seen,  but  a  track  of 
opacity  through  the  lens,  with  blood  in  the  vitreous,  or 
even  the  latter  alone,  with  conclusive  history  that  the 
wound  was  made  by  a  fragment  or  a  shot,  and  not  by  an 
instrument  or  large  body,  will  generally  decide  us  in  favor 
of  excision.  These  rules  need  some  modification  when  the 
foreign  body  is  of  iron  or  steel,  since  it  is  possible  in  certain 
cases,  by  means  of  a  strong  electro-magnet,  to  remove  such 
fragments,  even  when  lying  in  the  vitreous.  This  maybe 
done  either  through  the  wound  of  entrance  more  or  less 


186  INJURIES     OP     THE     EYEBALL. 

enlarged,  or  throuuh  a  fresh  wound  made  where  the  body 
is  seen  or  believed  to  lie.  Many  forms  of  magnet  have 
been  employed,  the  most  successful  usually  being  those  in 
which  a  probe-ended  instrument  powerfully  magnetized  by 
being  attached  to  the  core  of  an  electro-magnetic  coil,  is 
introduced  into  the  eye  in  search  of  the  body.  The  termi- 
nal of  the  instrument  used  at  Moorfields  will,  when  the 
circuit  is  complete,  lift  nine  ounces.  Though  a  certain 
number  of  eyes  have  now  been  saved  with  useful  sight  by 
means  of  the  magnet,  it  must  be  remembered  that  the  ex- 
traction of  the  foreign  body  does  not  insure  the  safety  of 
the  eye;  that  the  eye  may  inflame  or  shrink  and  remain 
as  potent  a  source  of  sympathetic  disease  as  before,  espe- 
cially so  if  iritis  or  threatened  panophthalmitis  were  present 
at  the  time  of  operation.^  Foreign  bodies  occasionally  be- 
come embedded  at  the  fundus  beyond  the  dangerous  region 
and  cause  no  further  trouble.  Iq  gunshot  cases  the  shot 
often  passes  out  through  a  counter-opening  and  remains 
without  doing  harm  in  the  orbit,  though  the  eye  is  de- 
stroyed. Occasionally  the  choroid  and  retina  are  damaged 
by  hemorrhage  caused  by  a  shot  or  bullet  traversing  the 
orbit  close  to  but  without  demonstrable  lesion  of  the 
sclerotic. 

(III.)  There  remain  cases  of  less  severe  character,  in 
which  there  is  no  foreign  body  in  the  eye  :  (1)  the  wound 
is  in  the  dangerous  region  and  complicated  with  traumatic 
cataract;  (2)  in  the  dangerous  region  without  traumatic 
cataract;  (3)  the  injury  is  entirely  corneal,  and  therefore 
not  in  the  dangerous  zone,  but  the  lens  and  iris  are 
wounded;  (4)  there  is  wound  of  cornea  and  iris  only,  the 

^  Mr.  Snell,  of  Sheffield,  who  has  probably  had  a  lar^rer  experience 
of  this  method  than  anyone  else,  has  published  (June,  1883)  an  excel- 
lent monograph,  in  which  all  the  cases  hitherto  recorded  are  p:iven,  in 
addition  to  his  own.  Hirschberg's  monograph  ou  the  subject  (1885) 
brings  the  subject  up  to  later  date. 


INJURIES     OF     THE     EYEBALL.  187 

lens  escaping.  In  group  (2)  there  will  often  be  much  diffi- 
culty in  deciding  what  to  do,  it  being  presumed  that  the 
wounded  eye  shows  no  iritis  or  other  signs  of  severe  inflam- 
mation ;  some  of  the  most  difficult  cases  are  those  of  wounds 
by  sharp  instruments  close  to  the  corneal  border,  with  con- 
siderable adhesion  of  the  iris,  or  in  which  there  is  evidence 
that  the  track  lies  between  the  lens  and  the  ciliary  pro- 
cesses, the  lens  not  being  wounded,  and  useful  sight  remain- 
ing. If  the  patient  be  seen  within  two  or  three  weeks  of 
the  injury,  and  the  sound  eye  show  no  irritation,  we  may 
safely  watch  the  case  for  a  few  days.  If  decided  sympa- 
thetic irritation  be  present  and  do  not  yield  after  a  few 
days'  treatment,  excision  is  advisable,  even  though  the  lens 
of  the  wounded  eye  be  uninjured.  In  regard  to  group  (1), 
excision  is  without  doubt  the  safest  course  in  all  cases, 
whether  or  not  the  eye  be  causing  sympathetic  symptoms, 
or  be  itself  especially  irritable ;  for  there  is  little  prospect 
of  regaining  useful  vision  in  an  eye  with  a  ciliary  wound 
and  traumatic  cataract.  In  group  (3 )  excision  is  necessary 
if  the  wound  be  very  large  or  irregular,  and  in  some  cases 
with  small  wound  but  persistent  symptoms.  In  group  (4) 
removal  of  the  eye  is  very  seldom  justifiable,  unless  the 
iris  having  healed  into  the  wound  chronic  inflammatory 
changes  are  present,  or  severe  iritis  and  threatened  pan- 
ophthalmitis come  on.  The  patient  in  all  open  cases  must 
be  warned,  and  must  be  seen  every  few  days  for  many 
weeks. 

When  sympathetic  ophthalmitis  has  set  in  before  the 
patient  asks  advice,  the  rule  as  to  the  excision  of  the  ex- 
citing eye  is  different. 

The  treatment  of  wounded  eyes  which  are  not  excised  is 
the  same  as  for  traumatic  iritis  and  cataract,  viz.,  atropine, 
rest,  and  local  depletion.  If  seen  before  inflammation 
(iritis)  has  begun,  ice  is  to  be  used.  If  the  iris  have  pro- 
lapsed  into  the  wound   the  protusion  should   be  drawn 


188  INJURIES     OF     THE     EYEBALL. 

further  out  and  a  large  piece  of  iris  cut  off  so  that  the  ends 
when  replaced  by  the  curette  may  retract  and  remain  quite 
free  from  the  wound,  see  Iridectomy;  this  may  be  done  as 
much  as  a  week  after  the  injury.  Even  when  seen  within 
an  hour  or  two  of  the  wound,  the  prolapse  can  seldom,  in 
my  experience,  be  either  returned  by  manipulation  or  made 
to  retract  by  eserine  or  atropine. 

It  is  sometimes  important  to  determine  whether  an  ex- 
cised eye  contain  a  foreign  body.  If  nothing  can  be  found 
in  the  blood  or  lymph,  etc.,  by  feeling  with  a  probe,  it  is 
best  to  crush  the  soft  parts,  little  by  little,  between  finger 
and  thumb,  when  the  smallest  particle  will  be  felt.  If  a 
shot  have  entered  and  left  the  eye,  the  counter-opening 
may,  if  recent,  be  found  from  the  inside,  although  no 
irregularity  be  noticeable  outside  the  eyeball. 


CHAPTER    XI. 

CATARACT. 

Cataract  means  opacity  of  the  crystalline  lens,  and  is 
due  to  changes  in  the  structure  and  composition  of  the  lens- 
fibres.  The  capsule  is  often  thickened,  but  otherwise  not 
much  altered.  The  changes  seldom  occur  throughout  the 
whole  lens  at  once,  but  begin  first  in  a  certain  region,  e.  g., 
the  centre,  nucleus,  or  the  superficial  layers,  cortex,  whilst 
in  some  forms  of  partial  cataract  the  change  never  spreads 
beyond  the  part  first  affected. 

Senile  changes  in  the  lens With  advancing  age  the 

lens,  which  is  from  birth  firmest  at  the  centre,  becomes 
harder,  and  acquires  a  very  decided  yellow  color  ;  its  re- 
fractive power  usually  decreases,  its  surface  reflects  more 
light,  and  its  substance  becomes  somewhat  fluorescent.  The 
result  of  all  these  changes  is,  that  at  an  advanced  age  the 
lens  is  more  easily  visible  than  in  early  life,  the  pupil  be- 
coming grayish  instead  of  being  quite  black.  This  grayness 
of  the  pupil  may  easily  be  mistaken  for  cataract,  but  oph- 
thalmoscopic examination  shows  that  the  lens  is  transparent, 
the  fundus  being  seen  without  any  appreciable  haze.  It  has 
hitherto  been  supposed  that  the  lens  became  smaller  in  old 
age,  but  the  researches  of  Priestley  Smith  have  lately 
shown  that  the  lens  continues  to  increase  in  all  dimensions, 
so  long  as  it  remains  transparent.  As  a  rule,  however, 
cataractous  lens  are  undersized. 

The  consistence  of  a  cataract  depends  chiefly  on  the 
patient's  age.  The  wide  physical  differences  between  cata- 
racts depend  less  on  variations  in  the  cause,  position,  or 


190  CATARACT. 

character  of  the  opacity  than  on  the  degree  of  natural 
hardness  which  is  proper  to  the  lens  at  the  time  when  the 
opacity  sets  in.  Below  about  thirty-five  all  cataracts  are 
"soft." 

Forms  of  General  Cataract. 

(1.)  Nuclear  cataract. — The  opacity  begins  in,  and  re- 
mains more  dense  at,  the  nucleus  of  the  lens,  thinning  off 
gradually  in  all  directions  toward  the  cortex,  Fig.  64;  the 
nucleus  is  not  really  opaque,  but  densely  hazy.  As  the 
patients  are  generally  old,  nuclear  cataract  is  usually  senile 
and  hard,  and  also  often  amber-colored  or  light  brownish, 
like  "  pea-soup"  fog. 

(2.)  Cortical  cataract — The  change  begins  in  the  super- 
ficial parts,  and  generally  takes  the  form  of  sharply  defined 
lines  or  streaks,  or  triangular  patches,  which  point  toward 
the  axis  of  the  lens,  and  whose  shape  is  dependent  on  the 
arrangement  of  the  lens  fibres,  Fig.  G5.  They  usually  begin 
at  the  edge,  equator,  of  the  lens,  where  they  are  hidden  by 
the  iris,  but  when  large  enough  they  encroach  on  the  pupil 
as  whitish  streaks  or  triangular  patches.  Theyatfect  both 
the  anterior  and  posterior  layers  of  the  lens,  and  the  inter- 
vening parts  may  be  quite  clear.  Sooner  or  later  the 
nucleus  also  becomes  hazy,  mixed  cataract,  and  the  whole 
lens  eventually  gets  opaque. 

Some  cases  of  the  large  class  known  as  "  senile"  or 
"  hard  "  cataract  are  nuclear  from  beginning  to  end,  i.  e., 
formed  by  gradual  extension  of  diS'used  opacity  from  the 
centre  to  the  surface ;  more  commonly  they  are  of  the 
mixed  variety. 

A  few  cataracts  beginning  at  the  nucleus,  and  many 
beginning  at  the  vortex,  are  not  senile  in  the  sense  of  ac- 
companying old  age,  and  are,  therefore,  not  hard.  Some 
such  are  caused  by  diabetes,  but  in  many  it  is  impossible 


PARTIAL    CATARACT.  191 

to  say  why  the  lens  should  have  become  diseased.'  Mey- 
hofer,  observing  that  opacities  in  the  lens  are  disproportion- 
ately common  in  glassblowers,  suggests  that  radiant  heat 
may  act  as  a  direct  cause  of  cataract.  Many  of  them  are 
known  as  "  soft"  cataracts  when  complete.  They  generally 
form  quickly,  in  a  few  months.  A  few  are  congenital. 
Whether  nuclear  or  cortical,  they  are  whiter  and  more 
uniform  looking  than  the  slower  cataracts  of  old  age,  and 
the  cortex  often  has  a  sheen,  like  satin  or  mother-of-pearl, 
or  looks  flaky  like  spermaceti. 

In  some  cortical  cataracts  we  find  only  numerous  very 
small  dots  or  short  streaks — "dotted  cortical  cataract." 
Occasionally  a  single  large  wedge-shaped  opacity  will  form 
at  some  part  of  the  cortex  and  remain  stationary  and  soli- 
tary for  many  years.  Sometimes  in  suspected  cataract, 
though  no  opaque  striae  are  visible  by  focal  illumination, 
one  or  more  dark  streaks,  "  striae  of  refraction" — Bowman, 
are  seen  with  the  mirror,  altering  as  its  inclination  is  varied, 
and  having  much  the  same  optical  effect  as  cracks  in  glass  ; 
these  "  flaws"  should  always  be  looked  on  as  the  beginning 
of  cataract. 

Partial  Cataract, 

Three  forms  need  special  notice. 

(1)  Lamellar  (zonular)  cataract  is  a  peculiar  and  well- 
marked  form  in  which  the  superficial  laminae  and  the 
nucleus  of  the  lens  are  clear,  a  layer  or  shell  of  opacity 
being  present  between  them,  Fig.  67.  An  examination  of 
three  or  four  specimens  here  and  abroad  shows  a  degene- 
rated layer  between  the  nucleus  and  cortex ;    in  all  the 

1  Lowered  blood  supply  from  atheroma  of  the  carotid  has  lately  been 
suffg'ested  as  a  cause  in  some  cases  (Michel ) .  Cataract  does  not  seem  to 
be  often  related  to  renal  disease  ;  but  when  renal  albuminuria  is  present 
In  a  case  of  cataract,  the  prognosis  for  operation  is  decidedly  less  favor- 
able than  usual. 


192  CATARACT. 

cases  the  nucleus  has  been  found  degenerated,  but  it  is  not 
yet  determined  whether  this  is  due  to  post-mortem  change 
or  not  (Lawford,  Beselin).  It  is  probable  that  the  opacity 
is  present  at  birth  ;  it  certainly  never  forms  late  in  life. 
The  great  majority  of  its  subjects  give  a  history  of  infantile 
convulsions  The  size  of  the  opaque  lamella  or  shell,  and 
therefore  its  depth  from  the  surface  of  the  lens,  is  subject 
to  much  variation,  and  it  may  be  much  smaller  than  is 
shown  in  the  figure.  The  opacity  is  often  stationary  for 
years,  perhaps  for  life,  but  cases  are  sometimes  met  with  in 
which  we  cannot  doubt,  from  the  history,  that  the  opacity 
has,  without  extending  perceptibly,  become  more  dense  ; 
instances  of  lamellar  opacity  spreading  to  the  whole  lens 
are,  however,  apparently  very  rare. 

(2)  Pyramidal  cataract. — A  small,  sharply-defined  spot 
of  chalky-white  opacity  is  present  in  the  middle  of  the 
pupil,  (at  the  anterior  pole  of  the  lens),  looking  as  if  it  lay 
upon  the  capsule.  When  viewed  sideways  it  seems  to  be 
superficially  embedded  in  the  lens,  and  also  sometimes 
stands  forward  as  a  little  nipple  or  pyramid.   Fig.  62.     It 

Fig.  62. 


J 
Pyramidal  cataract  seen  from  the  front  and  in  section. 

consists  of  the  degenerated  products  of  a  localized  inflam- 
mation just  beneath  the  lens-capsule,  with  the  addition  of 
organized  lymph  derived  from  the  iris  and  deposited  on 
the  front  of  the  capsule,  the  capsule  itself  being  puckered 
and  folded,  Fig.  63.  It  is  a  stationary  form,  scarcely  ever 
becoming  general. 

Pyramidal  cataract  is  the  result  of  central  perforating 
ulceration  of  the  cornea  in  early  life,  and  of  this  ophthalmia 
neonatorum  is  nearlv  alwavs  the  cause  ;  it  is,  therefore. 


PARTIAL    CATARACT, 


193 


often  associated  with  corneal  nebula.  The  contact  between 
the  exposed  part  of  the  lens-capsule  and  the  inflamed 
cornea,  which  occurs  when  the  aqueous  hasescaped  through 
the  hole  in  the  ulcer,  appears  to  set  up  the  localized  sub- 


FiG.  63. 


Magnified  section  through  a  pyramidal  cataract,with  the  immediately 
subjacent  layers.  The  fine  parallel  shading  shows  the  thickness  of  the 
opacity,  the  double  (black  and  white)  outline  is  the  capsule ;  above  and 
below  are  the  cortical  lens-fibres,  many  being  broken  up  into  globules 
beneath  the  opacity.  Lying  upon  the  puckered  capsule  over  the 
opacity  is  a  little  fibrous  tissue,  the  result  of  iritis. 

capsular  inflammation.  Iritis  in  very  early  life  may  also 
cause  similar  opacities  at  points  of  adhesion  between  the 
iris  and  lens. 

The  term  anterior  polar  cataract  is  applied  both  to  the 
form  just  described  and  to  certain  rare  cases  in  which  gen- 
eral cataract  begins  at  this  part  of  the  lens. 

(3)  Cataract,  which  afterwards  becomes  general,  may 
begin  as  a  thin  layer  at  the  middle  of  the  hinder  surface 
of  the  lens,  posterior  polar  cataract.  Fig.  66.  There  are 
many  varieties,  but  in  general  the  pole  itself  shows  the 
most  change,  the  opacity  radiating  outward  from  it  in  more 

9 


194  CATARACT. 

or  less  regular  spokes.  The  color  appears  grayish,  yellowish, 
or  even  brown,  because  seen  through  the  whole  thickness 
of  the  lens.  Sometimes  the  opacity  is  due  to  formations 
adherent  to  the  back  of  the  capsule,  i.  e.,  in  front  of  the 
vitreous  ;  but  this  can  seldom  be  proved  during  life.  Cata- 
ract beginning  at  the  posterior  pole  is  often  a  sign  of  dis- 
ease of  the  vitreous  depending  on  choroidal  mischief ;  it  is 
common  in  the  later  stages  of  retinitis  pigmentosa  and 
severe  choroiditis,  and  in  high  degrees  of  myopia  with  dis- 
ease of  the  vitreous.  The  prognosis,  therefore,  should  al- 
ways be  guarded  in  a  case  of  cataract  where  the  principal 
part  of  the  opacity  is  in  this  position. 

When  a  cataract  forms  without  known  connection  with 
other  disease  of  the  eye,  it  is  said  to  be  primary.  The  term 
secondary  cataract  is  used  when  it  is  the  consequence  of 
some  local  disease,  such  as  severe  irido-cyclitis,  glaucoma, 
detachment  of  the  retina,  or  the  growth  of  a  tumor  in  the 
eye.  Primary  cataract  is  symmetrical  in  most  cases,  but 
an  interval,  which  may  even  extend  to  several  j^ears, 
usually  separates  its  onset  in  the  two  eyes.  Secondary 
cataract,  of  course,  may  or  may  not  be  symmetrical. 

Diagnosis  of  Cataract. — The  subjective  symptoms  of 
cataract  depend  almost  solely  on  the  obstruction  and  dis- 
tortion of  the  entering  light  by  the  opacities.  Objectively, 
cataract  is  shown  in  advanced  cases  by  the  white  or  gray 
condition  of  the  pupil  at  the  plane  of  the  iris;  in  earlier 
stages  by  whitish  opacity  in  the  lens  when  examined  by 
focal  light,  and  by  corresponding  dark  portions,  lines,  spots, 
or  patches  in  the  red  pupil  when  examined  by  the  ophthal- 
moscope mirror. 

Both  subjective  and  objective  symptoms  differ  with  the 
position  and  quantity  of  the  opacity.  When  the  whole 
lens  is  opaque  the  pupil  is  uniformly  whitish  ;  the  opacity 
lies  almost  on  a  level  with  the  iris,  no  space  intervening, 
and  consequently,  on  examining  by  focal  light,  we  find 


DIAGNOSIS     OF     CATARACT.  195 

that  the  iris  casts  no  shadow  on  the  opacity ;  the  brightest 
light  from  the  mirror  will  not  penetrate  the  lens  in  quantity 
enough  to  illuminate  the  choroid,  and  hence  no  red  reflex 
will  be  obtained.  Such  a  cataract  is  said  to  be  mature  or 
"ripe,"  and  the  affected  eye  will  be,  in  ordinary  terms, 
"blind."  If  both  cataracts  be  equally  advanced,  the 
patient  will  be  unable  to  see  any  objects;  but  he  will  dis- 
tinguish quite  easily  between  light  and  shade  when  the 
eye  is  alternately  covered  and  uncovered  in  ordinary  day- 
light, good  perception  of  light,  p.  I.,  and  will  tell  correctly 
the  position  of  a  candle  flame  (good  projection).  The 
pupils  should  be  active  to  light  and  not  dilated,  the  tension 
normal. 

In  a  case  of  incipient  cataract  the  patient  complains  of 
gradual  failure  of  sight,  and  we  find  the  acuteness  of  vision 
impaired,  probably  more  in  one  eye  than  in  the  other,  and 
more  for  distant  than  for  near  objects.  In  the  earliest 
stages  of  senile  cataract  some  degree  of  myopia  may  be 
developed  (Chap.  XX.),  or,  owing  to  irregular  refraction 
by  the  lens,  the  patient  may  see  with  each  eye  two  or  more 
Images  of  any  object  close  together,  polyopia  uniocularis. 
If  he  can  still  read  moderate  type,  the  glasses  appropriate 
for  his  age  and  refraction,  though  giving  some  help,  do  not 
remove  the  defect.  If,  as  is  usual,  he  be  presbyopic,  he 
will  be  likely  to  choose  over-strong  spectacles,  and  to  place 
objects  too  close  to  his  eyes,  so  as  to  obtain  larger  retinal 
images,  and  thus  compensate  for  want  of  clearness.  In 
nuclear  cataract,  as  the  axial  rays  of  light  are  most  ob- 
structed, sight  is  often  better  when  the  pupil  is  rather 
large,  and  such  patients  tell  us  that  they  see  better  in  a 
dull  light,  or  with  the  back  to  the  window,  or  when  shading 
the  eyes  with  the  hand.  In  the  cortical  and  more  diffused 
forms  this  symptom  is  less  marked. 

On  examining  by  focal  light  (the  pupil  having  been  di- 
lated) an  immature  nuclear  cataract  appears  as  a  yellowish. 


196 


CATARACT 


rather  deeply-seated,  haze,  upon  which  a  shadow  is  cast  by 
the  iris  on  the  side  from  which  the  light  comes,  3,  Fig.  64. 
On  now  using  the  mirror  this  same  opacity  appears  as  a  dull 
blur  in  the  area  of  the  red  pupil,  darkest  at  the  centre, 

Fig.  64. 


Nuclear  cataract.  1.  Section  of  lens;  opacity  densest  at  centre.  2, 
Opacity  as  seen  by  transmitted  light  (ophthalmoscope  mirror)  with 
dilated  pupil.  3.  Opacity  as  seen  by  reflected  light  (focal  illumina- 
tion).    The  pupil  is  supposed  to  be  dilated  by  atropine. 

and  gradually  thinning  off  on  all  sides,  so  that,  at  the 
margin  of  the  pupil,  the  full  red  choroidal  reflex  may  still 
be  present ;  the  details  of  the  fundus,  if  still  visible,  are 
obscured  by  the  hazy  lens,  the  haze  being  thickest  when 
we  look  through  the  centre  of  the  pupil,  2,  Fig.  64.  If 
the  opacity  be  dense  and  large,  a  faint  dull  redness  will 
be  visible,  aiid  that  only  at  the  border  of  the  pupil. 

Cortical  opacities,  if  small  and  confined  to  the  equator, 
or  edge,  of  the  lens,  do  not  interfere  with  sight ;  they  are 
easily  detected  with  a  dilated  pupil  by  throwing  light  very 
obliquely  behind  the  iris.     When  large  and  encroaching 

Fig.  65. 


Cortical  cataract.    References  as  in  preceding  figure. 

on  the  pupil  they  are  visible  in  ordinary  daylight.  They 
occur  in  the  form  of  dots,  streaks,  or  wedges  ;  seen  by  focal 
light  they  are  white  or  grayish,  and  more  or  less  sharply 


DIAGNOSIS    OP    CATARACT.  197 

defined  according  as  they  are  in  the  anterior  or  posterior 
layers,  3,  Fig.  65.  With  the  mirror  they  appear  black  or 
grayish,  and  of  rather  smaller  size,  2,  Fig.  65  ;  and  if  the 
intervening  substance  be  clear,  the  details  of  the  fundus 
can  be  seen  sharply  between  the  bars  of  opacity.  Some 
forms  of  cataract  begin  with  innumerable  minute  dots  in 
the  cortical  layer. 

Posterior  polar  opacities  are  seldom  visible  without 
careful  focal  illumination,  when  we  find  a  patchy  or  stel- 
late figure  very  deeply  seated  in  the  axis  of  the  lens,  3,  Fig. 
66  ;  if  large  it  looks  concave,  like  the  bottom  of  a  shallow 
cup.  With  the  mirror  it  is  seen  as  a  dark  star,  2,  Fig.  66, 
or  network,  or  irregular  patch,  but  smaller  than  when  seen 
by  focal  light. 

The  diagnosis  of  lamellar  cataract  is  easy  if  its  nature 
be  understood,  but  by  beginners  it  is  often  diagnosed  as 
"nuclear."  The  patients  are  generally  children  or  young 
adults;   they   complain  of   "near   sight"  rather  than  of 


Fig.  66. 


1 


V7 
Posterior  polar  cataract.     References  as  before. 

"  cataract ;  "  for  the  opacity  is  not  usually  very  dense,  and 
whether  the  refraction  of  their  eyes  be  really  myopic  or 
not,  they  (like  other  cataractous  patients)  compensate  for 
dull  retinal  images  by  holding  the  object  nearer,  and  so 
increasing  the  size  of  the  images.  The  acuteness  of  vision 
is  always  defective,  and  cannot  be  fully  remedied  by  any 
glasses.  They  often  see  rather  better  when  the  pupils  are 
dilated  either  by  shading  the  eyes  or  by  means  of  atropine  ; 
in  the  latter  case  convex  glasses  (-f  4,  or  -f  4  D.)  are 
necessary  for  reading.     The  pupil  presents  a  deeply-seated, 


198 


OATA  RACT 


slight  grayness,  4,  Fig.  67,  and  when  dilated  with  atropine 
the  outline  of  the  shell  of  opacity  is  exposed  within  it. 
This  opacity  is  sharply  defined,  circular  and  whitish  by 
focal  light,  interspersed,  in  many  cases,  with  white  specks, 
which  at  its  equator  appear  as  little  projections,  3,  Fig. 
67.  By  focal  illumination  we  easily  make  out  that  the 
opacity  consists  of  two  distinct  layers,  that  there  is  a  layer 

Fig.  67. 


Lamellar  cataract.  Figs.  1,  2,  3,  as  before.  Fig.  4  shows  slight 
grayness  of  the  undilated  pupil,  owing  to  the  layers  of  opacity  being 
deeply  seated. 

of  clear  lens  substance,  cortex,  in  front  of  the  anterior 
layer,  and  that  the  margin,  equator,  of  the  lens  is  clear. 
By  the  mirror  the  opacity  appears  as  a  disc  of  nearly  uni- 
form grayish  or  dark  color,  sometimes  with  projections,  or 
darker  dots,  and  surrounded  b}^  a  zone  of  bright-red  re- 
flection from  the  fundus  corresponding  to  the  clear  margin 
of  the  lens,  2,  Fig.  67.  The  opacity  often  appears  rather 
denser  at  its  boundary,  a  sort  of  ring  being  formed  there, 
and  in  some  cases  quite  large  spicules  or  patches  project 
from  the  part.  Not  only  does  the  size  of  the  opaque 
lamella,  and,  therefore,  its  depth  from  the  surface  of  the 
lens,  differ  greatly  in  different  cases,  but  its  thickness  or 
degree  of  opacity  varies  also.  The  disease  is  nearly  always 
symmetrical  in  the  two  eyes.  Occasionally  there  are  two 
shells  of  opacity,  one  within  the  other,  separated  by  a  cer- 
tain amount  of  clear  lens  substance. 


PROGNOSIS     OF     CATARACT.  199 

The  lens  may  be  cataractous  at  birth,  congenital  cataract. 
This  form,  of  which  there  are  several  varieties,  is  nearly 
always  symmetrical,  and  generally  involves  the  whole 
lens.  Often  the  development  of  the  eyeball  is  defective, 
and  though  there  are  no  synechise,  the  iris  may  act  badly 
to  atropine.  Cases  are  seen  from  time  to  time  in  which 
juvenile  or  perhaps  congenital  cataract  appears  in  many 
members  of  a  family,  even  in  several  generations. 

Prognosis  of  Cataract,  a.  Course. — Although  opa- 
cities in  the  lens  never  clear  up,^  they  advance  with  very 
varying  rapidity  in  different  cases.  As  a  rough  rule,  the 
progress  of  a  general  cataract  is  rapid  in  proportion  to  the 
youth  of  the  patient,  Cataracts  in  old  people  commonly 
take  from  one  to  three  years  in  reaching  maturity — some- 
times much  longer ;  there  are  cases  of  nuclear  senile  cata- 
ract where  the  opacity  never  spreads  to  the  cortex,  and  the 
cataract  never  becomes  "  complete,"  though  it  may  become 
dry  and  "ripe"  for  operation.  If  the  lens  be  allowed  to 
remain  very  long  after  it  is  opaque,  further  degenerative 
changes  generally  occur ;  it  may  become  harder  and 
smaller,  calcareous  and  fatty  granules  being  formed  in  it ; 
or  the  cortex  may  liquefy  whilst  the  nucleus  remains  hard, 
Morgagnian  cataract.  A  congenital  cataract  may  undergo 
absorption  and  shrink  to  a  thin,  firm,  membranous  disc. 
Soft  cataract  in  young  adults,  from  whatever  cause,  is  gen- 
erally complete  in  a  few  months. 

b.  Sight. — The  prognosis  after  operation  is  good  when 
there  is  no  other  disease  of  the  eye,  and  when  the  patient 
(although  advanced  in  years)  is  in  fair  general  health.  It  is 
not  so  good  in  diabetes,  nor  when  the  patient  is  in  obvi- 
ously bad  health,  the  eyes  being  then  less  tolerant  of  opera- 
tion. In  the  lamellar  and  other  congenital  varieties  it  must  be 
guarded,  for  the  eyes  are  often  defective  in  other  respects, 

1  Except  sometimes  in  diabetes  (Chap.  XXIII.). 


200  CATARACT. 

and  sometimes  very  intolerant  of  operation  ;  the  intellect, 
too,  is  sometimes  defective,  rendering  the  patient  less  able 
to  make  proper  use  of  his  eyes.  In  traumatic  cataract,  of 
course,  everything  depends  on  the  details  of  the  injury,  but, 
as  a  rule,  the  younger  the  patient  the  better  the  prospect  of 
a  quiet  and  uncomplicated  absorption  of  the  lens. 

In  every  case  of  immature  cataract  the  vitreous  and 
fundus  should  be  carefully  examined  by  the  ophthalmo- 
scope, and  the  refraction  ascertained.  The  presence  of 
high  myopia  is  unfavorable,  and  the  same  is  true  of  opaci- 
ties in  the  vitreous,  indicating,  as  they  usually  do,  that  it 
is  fluid.  Any  disease  of  the  choroid  or  retina  will,  of 
course,  be  prejudicial  in  proportion  to  its  position  and 
extent.  In  every  case,  before  deciding  to  operate,  the  state 
of  the  conjunctiva  and  lachrymal  passages,  the  tension  of  the 
eye,  and  the  size  and  mobility  of  the  pupils  to  light,  are  to 
be  carefully  noted. 

Treatment. — In  the  early  stages  of  senile  and  nuclear 
cataract,  sight  is  improved  by  keeping  the  pupil  moderately 
dilated  with  a  weak  mydriatic  solution,  one-eighth  of  a 
grain  of  atropine  to  the  ounce,  used  about  three  times  a 
week.  Dark  glasses,  by  allowing  some  dilatation  of  the 
pupil,  also  assist.  Stenopaic  glasses  are  sometimes  useful. 
With  these  exceptions,  nothing  except  operative  treatment 
is  of  any  use.  The  management  of  lamellar  cataract 
requires  separate  description. 

Operations  for  the  removal  of  cataract  are  of  three 
kinds:  (1)  Extraction  of  the  lens  entire  through  a  large 
wound  in  the  cornea,  or  at  the  sclero-corneal  junction,  the 
lens-capsule  remaining  behind.  By  a  few  operators  the 
lens  is  removed  entire  in  its  capsule.  (2)  For  soft  cata- 
racts, gradual  absorption,  by  the  agency  of  the  aqueous 
humor  admitted  through  needle  punctures  in  the  capsule, 
just  after  accidental  traumatic  cataract-needle  operations, 
solution,  discission.    The  operation  needs  repetition  two  or 


EXTRACTION.  201 

three  times,  at  intervals  of  a  few  weeks,  and  the  whole 
process  therefore  occupies  three  or  four  months.  (3)  For 
soft  cataracts,  removal  by  a  suction  syringe  or  curette,  intvo- 
duced  into  the  anterior  chamber  through  a  small  wound 
near  the  margin  of  the  cornea,  the  whole  lens  having,  if 
thought  necessary,  been  freely  broken  up  by  a  discission 
operation  a  few  days  previously  (Chap.  XXII.). 

Extraction  is  necessary  for  cataracts  after  about  the  age 
of  forty.  The  lens  from  this  age  onwards  is  so  firm  that 
its  absorption  after  discission  occupies  a  much  longer  time 
than  in  childhood  and  youth  ;  moreover,  as  already  stated, 
the  swelling  of  the  lens,  after  wound  of  the  capsule,  is  less 
easily  borne  as  age  advances,  and  hence  solution  operations 
become  not  only  slower,  but  attended  by  more  danger. 
Indeed,  though  suction  and  solution  operations  are  ap- 
plicable up  to  about  the  age  of  thirty-five,  extraction  is 
often  practised  in  preference  at  a  much  earlier  age.  Suc- 
tion is  more  difficult,  and  it  is  thought  by  some  to  be 
attended  by  more  risk  of  irido-cyclitis  than  the  "  solution  '* 
operation  ;  its  advantage  lies  in  its  saving  of  time,  almost 
the  whole  lens  being  removed  at  one  sitting.  Evacuation 
along  the  groove  of  a  curette  barely  passed  through  the 
wound  is  a  very  safe  proceeding. 

If  one  present  a  complete  cataract  whilst  the  sight 
of  the  other  is  perfect,  or  at  least  serviceable,  removal  of 
the  cataract  will  confer  little  immediate  benefit  to  the 
patient.  Indeed,  if  one  eye  be  still  fairly  good,  the  patient 
will  often  be  dissatisfied  by  finding  his  operated  eye  less 
useful  than  he  expected,  perhaps  even  not  so  useful  as  the 
other.  In  senile  cataract,  therefore,  it  is  usually  best  not 
to  operate  so  long  as  the  lens  of  the  other  eye  remains 
nearly  clear  ;  but  so  soon  as  it  becomes  sufficiently  a6*ected 
to  interfere  seriously  with  vision,  extraction  of  the  cataract 
from  the  first  is  advisable,  provided  that  the  patient  have  a 
fair  prospect  of  life.     The  cataract  in  the  first  eye  may  be 


202  CATARACT. 

over-ripe  and  less  favorable  for  operation,  if  it  be  left  until 
the  second  eye  be  quite  ready.  The  removal  of  a  single 
cataract  in  3'oung  persons  is  often  expedient  on  account  of 
appearance.  In  all  cases  of  single  cataract  it  must  be 
explained  that  after  the  operation  the  two  eyes  will  not 
work  together  on  account  of  the  extreme  difference  of  re- 
fraction.    See  Anisometropia. 

Even  when  both  cataracts  are  mature  at  the  same  time, 
it  is  safer  to  remove  only  one  at  once,  because  the  after- 
treatment  is  more  easily  carried  out  upon  one  eye  than 
both,  and  because  after  the  double  operation  any  untoward 
result  in  one  eye  adds  to  the  difficulty  of  managing  its 
fellow  ;  while  a  bad  result  after  single  extraction  enables 
us  to  take  especial  precautions,  or  to  modify  the  operation 
for  the  second  eye.  Even  if  the  patient  be  so  old  or  feeble 
that  the  second  eye  may  never  come  to  operation,  we  shall 
consult  his  interests  better  by  endeavoring  to  give  him  one 
good  eye  than  by  risking  a  bad  result  in  attempting  to  re- 
store both  at  the  same  time. 

Cataract  occurring  after  the  age  of  forty  can  seldom  be 
safely  extracted  until  it  is  complete  or  "  ripe."  The  trans- 
parent portions  of  an  immature  cataract  cannot  be  com- 
pletely removed,  partly  because  they  are  sticky,  partly 
because  they  cannot  be  seen  ;  and,  remaining  behind  in 
the  eye,  they  act  as  irritants  and  often  set  up  iritis.  In- 
complete juvenile  cataract,  e.  g.,  lamellar  cataract,  may  be 
safely  ripened  by  tearing  the  capsule  with  a  needle  (see 
Discission  and  Suction)  ;  but  hard  cataract  cannot  be  so 
treated  because  the  lens  is  too  hard  to  absorb  the  aqueous 
well,  and  the  senile  eye  is  intolerant  of  injury  to  the  lens. 

Some  years  ago,  Professor  Forster,  of  Breslau,  proposed  a 
plan  for  hastening  the  completion  of  very  slow  senile  cataracts: 
immediately  after  the  iridectomy  he  bruises  the  lens  by  rubbing 
the  cornea  firmly  over  the  pupil  with  a  cataract  spoon  or  other 
smooth  instrument  :  the  capsule  is  not  ruptured,  but  the  lens- 


FAILURES     AFTER     EXTRACTION.  203 

fibres  are  broken  up  or  so  changed  that  they  often  become 
opaque  a  few  weeks  or  months  after.  Priestley  Smith  and 
others  adopt  the  safer  plan  of  bruising  the  lens  directly  by 
means  of  a  small  bulbous  spatula  passed  through  the  corneal 
wound.  These  methods  are  very  uncertain,  sometimes  having 
no  effect,  but  the  latter  modification  maybe  employed  without 
risk  in  suitable  cases.  More  recently  McKeown  and  Wicker- 
kiewicz  have  advocated  the  plan  of  washing  out  the  capsule, 
after  expulsion  of  the  bulk  of  the  lens,  by  means  of  a  stream 
of  water  or  weak  antiseptic  lotion  :  eithera  syringe  or  S3*phon 
may  be  used.  The  authors  hope  that  this  proceeding,  by  facil- 
itating the  removal  of  clear  cortical  matter,  will  render  the 
extraction  of  immature  senile  cataract  safe  and  expedient.  It 
must  be  borne  in  mind,  however,  that  the  lens  substance  is  more 
sticky  and  adherent  to  the  capsule  when  clear,  and  that,  there- 
fore, it  ma}-  be  most  difficult  of  removal  by  this  method,  as  by 
others,  just  when  its  removal  is  most  important.  The  method 
is  heing  largeh'  tried  by  several  operators. 

The  principal  causes  of  failure  after  extraction  of  cata- 
ract are — 

(I.)  Hemorrhage  between  the  choroid  and  sclerotic  com- 
ing on,  usually  with  severe  pain,  immediately  after  the 
operation.  The  blood  fills  the  eyeball,  and  often  oozes 
from  the  wound  and  soaks  through  the  bandage. 

(2.)  Suppuration,  beginning  in  the  corneal  wound, 
spreading  to  the  iris  and  vitreous,  and  in  many  to  the 
entire  cornea,  and  ending  in  a  total  loss  of  the  eye.  It 
occasionally  takes  a  less  rapid  course,  and  stops  short  of  a 
fatal  result.  The  alarm  is  given  in  from  twelve  hours  to 
about  three  days  after  operation  by  the  occurrence  of  pain, 
inflammatory  oedema  of  the  lids,  particularly  the  free 
border  of  the  upper  lid,  and  the  appearance  of  some  muco- 
purulent discharge.  On  raising  the  lid  the  eye  is  found  to 
be  greatly  congested,  its  conjunctiva  oedematous,  the  edges 
of  the  wound  yellowish,  and  the  cornea  steamy  and  hazy. 
In  very  rapid  cases  the  pupil,  especially  near  to  the  wound, 


:10i  CATARACT. 

will  already  be  occupied  by  lymph.  Suppuration  i.s  prob- 
ably always  caused  by  infection,  though  the  source  of  the 
mischief  of  course  often  remains  hidden.  Chronic  dacryo- 
cystitis is  a  very  dangerous  concomitant  of  cataract  opera- 
tions, the  pus  escaping  through  the  puncta  and  infecting 
the  wound.  Suppuration  is  more  probable  if  the  wound 
lie  in  clear  corneal  tissue  than  if  it  be  partly  scleral,  and 
if  the  patient  be  in  bad  or  feeble  health. 

The  use  of  hot  fomentations  for  an  hour  three  or  four 
times  a  day,  leeches,  if  there  be  much  pain,  and  internally 
a  purge,  followed  by  quinine  and  ammonia,  and  wine  or 
brandy  if  the  patient  be  feeble,  should  be  at  once  resorted 
to.  As  to  other  measures,  opinions  differ.  From  w^hat  I 
have  seen  of  my  own  and  others'  cases  I  am,  at  present, 
inclined  to  agree  with  Horner  and  those  who  direct  most 
attention  to  the  vigorous  antiseptic  treatment  of  the  wound 
itself;  I  have  found  that  the  actual  (galvano-)  cautery 
applied  deeply  along  the  whole  length  of  the  w^ound  is  more 
successful  than  any  other  measures,  assisted,  however,  by 
hot  fomentations,  and  the  use  of  iodoform  or  of  weak 
lotions  of  chloride  of  zinc  or  bichloride  of  mercury,  and  by 
leaving  the  eye  open.'  But  only  in  the  cases  of  moderate 
rapidity  and  intensity  can  we  hope,  even  partly,  to  arrest 
the  disease,  for  the  great  majority^  of  these  cases  go  on  to 
suppurative  panophthalmitis,  or  to  severe  plastic  irido- 
cyclitis with  opacity  of  cornea  and  shrinking  of  the  eyeball. 

(3.)  Iritis  may  set  in  between  about  the  fourth  and  tenth 
days.  Here  also  pain,  oedema  of  the  eyelids,  and  chemosis 
are  the  earliest  symptoms.  There  is  lachrymation,  but 
no  muco-purulent  discharge,  and  the  cornea  and  wound 
usually  remain  clear.  The  iris  is  discolored  (unless  it 
happen  to  be  naturally  greenish-brown),  and  the  pupil  di- 
lates badly  to  atropine.     Whenever,  in  a  ca.se  presenting 

1  Mr.  C.  T.  Collins,  our  house  surgeon  at  Moorfields,  suggested  to  me 
the  la&t-named  measure. 


FAILURES     AFTER     EXTRACTION.  205 

such  symptoms,  a  good  examination  is  rendered  difficult 
on  account  of  the  photophobia,  iritis  should  be  suspected. 
If  the  early  symptoms  are  severe,  a  few  leeches  to  the 
temples  are  very  useful.  Atropine  and  warmth  are  the 
best  local  measures.  If  atropine  irritate,  daturine  or  du- 
boisine  should  be  tried  (F.  32,  33). 

This  inflammation  is  plastic,  ending  in  the  formation  of 
more  or  less  dense  membrane  in  the  pupil.  Such  mem- 
brane by  contracting  and  drawing  the  iris  with  it  toward 
the  operation  scar  often  contracts  and  displaces  the  pupil. 
Fig.  161  shows  this  in  an  extreme  degree.  The  membrane 
is  formed  partly  by  exudation  from  the  iris  and  ciliary 
processes,  iritis,  cyclitis,  partly  by  the  lens-capsule  and  its 
proliferated  endothelial  cells,  capsulitis.  Mixed  forms  of 
chronic  keratitis  and  iritis  sometimes  occur,  the  corneal 
haze  spreading  from  the  wound  in  the  form  of  long  lines 
or  stripes.  Iritis  of  obstinately  plastic  type  is  liable  to 
occur  after  extraction  of  cataract  in  diabetes. 

(4.)  The  iris  may  become  incarcerated  in  or  prolapse 
through  the  w^ound  at  the  operation  or  a  few  days  after- 
ward by  the  reopening  of  a  weakly  united  wound.  When 
iridectomy  has  been  done  the  prolapse  appears  as  a  little 
dark  bulging  at  one  or  both  ends  of  the  wound,  and  often 
causes  prolonged  irritability,  without  actual  iritis.  The 
best  treatment  is  to  draw  the  protruding  part  further 
out,  and  to  cut  it  off  as  freely  as  possible,  as  in  acci- 
dental wounds.  The  occurrence  of  prolapse  is  a  reason  for 
keeping  the  eye  tied  up  longer.  The  capsule  may  also  be 
incarcerated  in  or  adherent  to  the  wound  after  extraction, 
suction,  or  curette,  simple  linear  extraction.  After-opera- 
tions are  needed  if  the  pupil  be  much  obstructed  by  cap- 
sular opacities  or  by  the  results  of  iritis ;  but  nothing 
should  be  done  until  active  symptoms  have  subsided  and 
the  eye  been  quiet  for  some  weeks. 


206  CATARACT. 

Sight  after  the  removal  of  cataract. — In  accounting  for 
the  state  of  the  sight  we  have  to  remember  that  the  acute- 
ness  of  sight  naturally  decreases  in  old  age;  that  slight 
iritis,  producing  a  little  filmy  opacity  in  the  pupil,  is  com- 
mon after  extraction;  and  that  some  eyes  with  good  sight 
remain  irritable  for  long  after  the  operation,  and  therefore 
cannot  be  much  used.  Thus,  putting  aside  the  graver 
complications,  we  find  that  even  of  the  eyes  which  do  best 
only  a  moderate  proportion  reach  normal  acuteness  of 
vision.  Cases  are  considered  good  when  the  patient  can 
with  his  glasses  read  anything  between  Nos.  1  and  14 
Jaeger  and  y^^  Snellen;  but  a  much  less  satisfactory  result 
than  this  is  very  useful.  About  5  per  cent,  of  the  eyes 
operated  upon  are  lost  from  various  causes.  The  eye  is 
rendered  extremely  hypermetropic  by  removal  of  the  lens, 
and  frequently  there  is  a  good  deal  of  astigmatism  due  to 
flattening  of  that  meridian  of  the  cornea  which  is  at  a 
right  angle  with  the  operation  wound.  Strong  convex 
glasses  are  necessary  for  clear  vision  ;  these  should  seldom 
be  allowed  until  three  months  after  the  operation,  and  at 
first  they  should  not  be  continuously  worn.  Two  pairs  are 
needed ;  one  makes  the  eye  emmetropic  and  gives  clear 
distant  vision  (+10  or  H  D.) ;  the  other  (about  +  16  D.) 
is  for  reading,  sewing,  etc.,  at  about  10'^  (25  cm.),  as  dur- 
ing strong  accommodation.  When  there  is  astigmatism  it 
should  usually  be  corrected.  As  all  accommodation  is 
lost,  the  patient  has  no  range  of  distinct  vision. 

Lamellar  cataract. — If  the  patient  can  see  enough  to 
get  on  fairly  well  at  school,  or  in  his  occupation,  it  maybe 
best  not  to  operate;  but  when,  as  is  the  rule,  the  opacity  is 
dense  enough  to  interfere  seriously  with  his  prospects, 
something  must  be  done.  The  choice  lies  between  artificial 
pupil  when  the  clear  margin  is  wide  and  quite  free  from 
spicules,  and  solution  or  extraction  when  it  is  narrow,  or 
when  large   spicules  of  opacity   project  into  it  from  the 


CATARACT  FOLLOWING  INJURY.      207 

opaque  lamella,  Fig.  67.  It  is  difficult  to  say  which  method 
gives  on  the  whole  the  better  results,  and  we  must  judge 
each  case  on  its  own  merits.  If  atropine,  b}^  dilating  the 
pupil,  improves  the  sight,  an  artificial  pupil,  made  by  re- 
moving the  iris  quite  up  to  its  ciliary  border,  will  generally 
be  beneficial ;  the  clear  border  of  the  lens  is  thus  exposed 
in  the  coloboma,  and  light  passes  through  it  more  readil}^ 
than  through  the  hazy  part.  A  very  good  rule  is  to  ope- 
rate on  only  one  eye  at  a  time,  thus  allowing  the  choice  of 
a  different  operation  on  its  fellow.  My  own  experience  is 
decidedly  in  favor  of  removing  the  lens  in  the  majorit}'"  of 
cases. 

When  a  cataractous  eye  is  absolutely  blind  (no  p.  1.,  see 
p.  49),  some  more  deeply-seated  disease  must  be  present, 
and  no  operation  should  be  undertaken ;  and  when  projec- 
tion and  p.  1.  are  bad,  great  caution  is  needed. 

Cataract  following  injury Severe  blows  on  the  eye 

may  be  followed  by  opacity  of  the  lens,  the  capsule  and 
often  the  suspensory  ligament  being  no  doubt  torn  in  some 
part,  concussion  cataract.  Lawford  has  shown  that  rupture 
of  the  posterior  capsule  may  occur  from  a  blow,  while  the 
anterior  capsule  remains  intact  (Ophth.  Rev.,  vi.  281). 
Such  a  cataract  may  remain  incomplete  and  stationary  for 
an  indefinite  period,  but  often  it  becomes  complete.  Trau- 
matic cataract  proper  is  the  result  of  wound  of  the  lens- 
capsule  ;  the  aqueous  passing  through  the  aperture  is  im- 
bibed by  the  lens-fibres,  which  swell  up,  become  opaque, 
and  finally  disintegrate  and  are  absorbed.  The  opacity 
begins  within  a  few  hours  of  the  wound;  it  progresses 
quickly  in  proportion  as  the  wound  is  large  and  the  patient 
young ;  but  both  the  symptoms  and  consequences  are  often 
more  severe  in  old  persons.  A  free  wound  of  the  capsule, 
followed  by  rapid  swelling  of  the  whole  lens,  may  give  rise, 
especially  after  middle  life,  to  severe  glaucomatous  symp- 
toms and  iritis.     In  from  three  to  six  months  a  w^ounded 


208  CATARACT. 

lens  will  generally  be  absorbed,  and  nothing  but  some 
chalky-looking  detritus  remain  in  connection  with  the  cap- 
sule. A  very  fine  puncture  of  the  lens  is  occasionally 
followed  by  nothing  more  than  a  small  patch  or  narrow 
track  of  opacity,  or  by  very  slowly  advancing  general 
haze.  Occasionally  partial  opacities  of  the  lens  caused  by 
injury  clear  up  entirely.  The  objects  of  treatment  are  to 
prevent  iritis  by  atropine,  and  by  leeching  if  there  be  pain  ; 
it  is  usually  safest  to  leave  the  wounded  lens  to  become 
absorbed,  but  we  must  be  prepared  to  extract  it  by  linear 
operation  or  suction  at  any  time,  should  glaucoma,  iritis,  or 
severe  irritation  arise.  A  concussion  cataract,  however,  is 
seldom  completely  absorbed ;  the  lens  shrinks  and  may 
then  become  loosened,  and  fall  either  into  the  vitreous  or 
aqueous  chamber.  I  believe,  therefore,  that  it  is  usually 
best  to  remove  by  operation  a  cataract  following  a  blow. 
It  will  often  be  observed  in  both  these  forms  of  cataract 
that  the  opacity  appears  at  the  posterior  surface  of  the  lens 
quite  early,  whether  the  wound  have  penetrated  deeply  or 
not. 

Dislocation  of  the  lens  in  its  capsule  is  usually  caused 
by  a  blow  on  the  eye,  but  may  be  spontaneous,  or  congeni- 
tal ;  in  either  case  it  is,  as  a  rule  only  partial.  The  iris 
is  often  tremulous  where  its  support  is  lost,  and  bulged 
forward  at  some  other  part  where  the  lens  rests  against  it ; 
by  focal  light,  or  by  the  ophthalmoscope,  the  free  edge  of 
the  lens  can  be  seen  as  a  curved  line  passing  across  the 
pupil;  more  easily  if  the  pupil  be  dilated.  More  rarely 
the  dislocation  is  incomplete,  either  into  the  vitreous  or  into 
the  anterior  chamber.  A  full-sized  lens  dislocated  into  the 
anterior  chamber  causes  acute  glaucoma.  Glaucoma,  acute 
or  chronic,  may  also  follow  at  any  time  after  a  dislocation, 
either  partial  or  complete,  into  the  vitreous.  Dislocated 
lenses  often  become  opaque  and  shrunken,  and  then  either 
remain  loose  or  become  adherent,  and  in  either  event  are 


DISLOCATION     OF     THE     LENS.  209 

likely,  sooner  or  later,  to  set  up  irritation  and  pain.  Such 
a  lens  may  sometimes  be  made  to  pass  at  will  through  the 
pupil  by  altering  the  position  of  the  head.  The  edge  of  a 
transparent  lens  in  the  vitreous  appears,  by  the  mirror,  as 
a  dark  line ;  when  in  the  anterior  chamber  it  appears  as  a 
bright  line,  by  focal  illumination.  Congenital  dislocation 
of  the  lens  is  often  accompanied  by  other  defects  of  devel- 
opment, such  as  coloboma. 

For  dislocation  of  lens  beneath  conjunctiva  in  rupture 
of  eye,  see  p.  178. 


CHAPTER    XII. 

DISEASES    OF    THE    CHOROID. 

The  choroid  is,  next  to  the  ciliary  processes,  the  most 
vascular  part  of  the  eyeball,  and  from  it  the  outer  layers 
of  the  retina,  certainly,  and  the  vitreous  humor  probably, 
are  mainly  nourished.  Inflammator}^  and  degenerative 
changes  often  occur,  some  of  them  entirely  local,  as  in 
myopia,  others  symptomatic  of  constitutional  or  of  general- 
ized disease,  such  as  syphilis  and  tuberculosis.  Choroiditis, 
unlike  inflammation  of  its  continuations,  the  ciliary  body 
and  iris,  is  seldom  shown  by  external  congestion  or  severe 
pain  ;  and  as  none  of  its  symptoms  are  characteristic,  the 
diagnosis  rests  chiefly  on  ophthalmoscopie  evidence. 

Blemishes  or  scars,  permanent  and  easily  seen,  nearly 
always  follow  disease  of  the  choroid,  and  such  spots  and 
patches  are  often  as  useful  for  diagnosis  as  cicatrices  on  the 
skin,  and  deserve  as  careful  study.  The  retina  lying  over 
an  inflamed  choroid  often  takes  on  active  changes,  or  be- 
comes atrophied  afterwards  ;  but  in  other  cases,  marked  by 
equally  severe  changes,  the  retina  is  uninjured.  Indeed, 
there  is  sometimes  difficulty  in  deciding  which  of  these  two 
structures  was  first  affected,  especially  as  changes  in  the 
pigment  epithelium,  which  is  really  part  of  the  retina,  are 
as  often  the  result  of  deep-seated  retinitis,  or  retinal  hemor- 
rhage, as  of  superficial  choroiditis.  Patches  of  accumulated 
pigment,  though  usually  indicating  spots  of  former  choroid- 
itis, are  sometimes  the  result  of  bleeding,  either  from  reti- 
nal or  choroidal  vessels,  and  their  correct  interpretation 
mav  therefore  be  difficult. 


DISEASES     OF     THE     CHOROID.  211 

Appearances  in  health. — The  choroid  is  composed  chiefly 
of  bloodvessels  and  of  cells  containing  dark-brown  pigment. 
The  quantity  of  pigment  varies  in  different  eyes,  and  to 
some  degree  in  different  parts  of  the  same  eye  ;  it  is  scanty 
in  early  childhood,  and  in  persons  of  fair  complexion  ;  more 
abundant  in  persons  with  dark  or  red  hair,  brown  irides, 
or  freckled  skin ;  more  plentiful  in  the  region  of  the  yellow 
spot  than  elsewhere.  In  old  age  the  pigment  epithelium 
becomes  paler.  When  examining  the  choroid  we  need  to 
think  of  four  parts  :  (1)  the  retinal  pigmented  epithelium, 
which  is  for  ophthalmoscopic  purposes  choroidal,  seen  in 
the  erect  image  as  a  fine  darkish  stippling  ;  (2)  the  capil- 
lary layer,  chorio-capillaris,  just  beneath  the  epithelium, 
forming  a  very  close  mesh  work,  the  separate  vessels  of 
which  are  not  visible  in  life;  (3)  the  larger  bloodvessels, 
often  easily  visible  ;  (4)  the  pigmented  connective-tissue 
cells  of  the  choroid  proper,  which  lie  between  the  larger 
vessels. 

In  the  majority  of  eyes  these  four  structures  are  so  toned 
as  to  give  a  nearly  uniform,  full  red  color  by  the  ophthal- 
moscope, blood-color  predominating.  In  very  dark  races 
the  pigment  is  so  excessive  that  the  fundus  has  a  uniform 
slaty  color.  In  very  fair  persons,  and  young  children,  the 
deep  pigment  (4)  is  so  scanty  that  the  large  vessels  are 
separated  by  spaces  of  lighter  color  than  themselves.  Fig. 
34.  In  dark  persons  these  same  spaces  are  of  a  deeper  hue 
than  the  vessels,  the  latter  appearing  like  light  streams 
separated  by  dark  islands  {see  upper  part  of  Fig.  70). 
Xear  to  the  disc  and  y.  s.  the  vessels  are  extremely  abun- 
dant and  very  tortuous,  the  interspaces  being  small  and 
irregular  ;  but  toward  and  in  front  of  the  equator  the  veins 
take  a  nearly  straight  course,  converging  toward  the  venas 
vorticosae,  and  the  islands  are  larger  and  elongated.  The 
veins  are  much  more  numerous  and  larger  than  the  arteries. 
Fig.  69,  but  we  cannot  often  distinguish  between  them  in 


212  DISEASES    OF    THE    CHOROID. 

life.  The  vessels  of  the  choroid,  unlike  those  of  the  retina, 
present  no  light  streak  along  the  centre.  The  pigment 
epithelium  and  the  capillary  layer  tone  down  the  above 
contrasts,  and  so  in  old  age,  when  the  epithelium  pigment 
is  bleached,  or  if  the  capillary  layer  be  atrophied  after 
superficial  choroiditis.  Fig.  70,  a  and  h,  the  above  distinc- 
tions become  very  marked. 

A  vertical  section  of  naturally  injected  human  choroid 
is  shown  in  Fig.  68  ;  the  uppermost  dark  line  (1)  is  the 
pigment  epithelium  ;  next  are  seen  the  capillary  vessels  (2), 
cut  across ;  then  the  more  deeply-seated  large  vessels  (3), 
and  the  deep  layer  of  stellate  pigment-cells  of  the  choroid 
proper  (4).  Fig.  69  is  from  an  artificially  injected  human 
choroid  seen  from  the  inner  surface.  The  shaded  portion 
is  intended  to  represent  the  general  effect  produced  by  all 
the  vessels  and  the  pigment  epithelium.  'I'he  lower  part 
shows  the  large  vessels  with  their  elongated  interspaces,  as 
may  be  seen  in  a  case  where  the  pigment  epithelium  and 
chorio-capillaris  are  atrophied,  Fig.  70,  6  ;  in  a  dark  eye  the 
interspaces  in  Fig.  69  would  be  darker  than  the  vessels. 

Fig.  68. 

Human  choroid,  vertical  section.     Naturally  injected.     X  20. 

The  middle  part  shows  the  capillaries  without  the  pigment 
epithelium.  Both  figures  are  magnified  about  four  times  as 
much  as  the  image  in  the  indirect  o{?hthalmoscopic  exami- 
nation. 

Ophthalmoscopic  Signs  of  Disease  of  the  Choroid. 

The  changes  usually  met  with  are  indicative  of  atrophy. 
This  may  be  partial  or  complete:  primary,  or  following 
inflammation  or  hemorrhage ;  in  circumscribed  spots  and 


DISEASES     OF    THE    CHOROID. 


213 


patches,  or  in  large  and  less  abruptly  bounded  areas.     Sec- 
ondary  changes   are  often  present  in  the  corresponding 


Fig.  69. 


y\ 


Vessels  of  human  choroid  artificially  injected.  Arteries  cross-shaded. 
Capillaries  too  dark  and  rather  too  small.  The  uppermost  shaded  part 
is  meant  to  represent  the  effect  of  the  pigment  epithelium.     X  20. 


parts  of  the  retina.  The  chief  signs  of  atrophy  of  the 
choroid  are  (1)  the  substitution  of  a  paler  color,  varying 
from  pale  red  to  yellowish-white,  for  the  full  red  of  health, 
the  subjacent  white  sclerotic  beinof  more  or  less  visible 


214 


DISEASES     OF     THE     CHOROID. 


where  the  atrophic  changes  have  occurred;  (2)  black  pig- 
ment in  spots,  patches,  or  rings,  and  in  varying  quantity 
upon  or  around  the  pale  patches.  These  pigmentations 
result,  1st,  from  disturbance  and  heaping  together  of  the 
normal  pigment ;  2d,  from  increase  in  its  quantity  ;  3d,  from 
blood-coloring  matter  left  after  extravasation.  Patches  of 
primar}"  atrophy,  e.g.,  in  myopia,  are  never  much  pigmented 
unless  bleeding  have  taken  place.  The  amount  of  pig- 
mentation in  atrophy  following  choroiditis  is  closely  related 
to  that  of  the  healthy  choroid,  i.  e.,  to  the  complexion  of 
the  person. 

Fig.  70. 


Atrophy  after  syphilitic  choroiditis,  showing  various  degrees  of 
wasting  (Hutchinson),  a.  Atrophy  of  pigment  epithelium.  6.  Atrophy 
of  epithelium  and  chorio-capillaris  ;  the  large  vessels  exposed,  c.  Spots 
of  complete  atrophy,  many  with  pigment  accumulation. 

Pigment  at  the  fundus  may  lie  in  the  retina  as  well  as 
in,  or  on,  the  choroid,  and  this  is  true  w^hatever  may  have 
been  its  origin,  for  in  choroiditis  with  secondary  retinitis 
the  choroidal  pigment  often  passes  forward  into  the  retina. 
When  a  spot  of  pigment  is  distinctly  seen  to  cover  over  a 


DISEASES     OF     THE     CHOROID.  215 

retinal  vessel,  that  spot  must  be  not  only  in,  but  very  near 
the  anterior  (inner)  surface  of,  the  retina ;  and  when  the 
pigment  has  a  linear,  mossy  or  lace-like  pattern,  Fig.  81, 
it  is  always  in  the  retina ;  these  are  the  only  conclusive 
tests  of  its  position. 

It  is  important,  and  usually  easy,  to  distinguish  between 
partial  and  complete  atrophy  of  the  choroid.  In  superficial 
atrophy,  affecting  the  pigment  epithelium  and  capillary 
layer,  the  large  vessels  are  peculiarly  distinct,  Fig.  70,  a 
and  h.  Such  "capillary"  or  "epithelial-'  choroiditis  often 
covers  a  large  surface,  the  boundaries  of  which  are  some- 
times well-defined,  sinuous  and  map-like,  but  are  as  often 

Fig.  71. 


ill-marked  ;  in  the  latter  case  we  must  carefully  compare 
different  parts  of  the  fundus,  and  also  make  allowance  for 
the  patient's  age  and  complexion.  Complete  atrophy  is 
shown  by  the  presence  of  patches  of  white  or  yellowish- 
white  color  of  all  possible  variations  in  size,  with  sharply- 
cut,  circular  or  undulating  borders,  and  with  or  without 
pigment  accumulations,  Figs.  TO,  c,  and  71.     The  retinal 


216 


DISEASES    OF    THE     CHOROID, 


vessels  pass  unobscured  over  patches  of  atrophied  choroid, 
proving  that  the  appearance  is  caused  bj  some  change 
deeper  than  the  surface  of  the  retina. 

If  the  patient  comes  with  recent  choroiditis,  we  also  often 
see  patches  of  palish  color,  but  they  are  less  sharply- 
bounded  and  frequently  of  a  grayer  or  whiter  (less  yellow) 
color  than  patches  of  atrophy  ;  moreover,  the  edge  of  such 

Fig.  72. 


Minute  exudations  into  inner  layer  of  choroid  in  sj'philitic  choroid- 
itis. Pigment  epithelium  adherent  over  the  exudations,  but  elsewhere 
has  been  washed  off.     Ch.  Choroid.     Scl.  Sclerotic. 


a  patch  is  softened,  the  texture  of  the  choroid  being  dimly 
visible  there,  because  only  partly  veiled  by  exudation.  If 
the  overlying  retina  be  unaffected,  its  vessels  are  clearly 
seen  over  the  diseased  part;  but  if  the  retina  itself  is  hazy 
or  opaque,  the  exact  seat  of  the  exudation  often  cannot  be 

Fig.  73. 


Section  of  miliary  tubercle.  Inner  layers  of  choroid  comparatively 
unaffected.  The  li£^hter  shading,  surrounding  an  artery  in  the  deepest 
part  of  the  tubercle,  represents  the  oldest  part,  which  is  caseating;  an 
artery  is  seen  cut  across  in  this  part  of  the  tubercle. 


at  once  decided,  and  this  difiBculty  is  often  increased,  by 
the  hazy  state  of  the  vitreous. 

Syphilitic  choroiditis  begins  in,  and  is  often  confined  to, 
the  inner  (capillary)  layer  of  the  choroid,  Fig.  72,  and 


DISEASES     OF     THE     CHOROID.  217 

hence  it  often  affects  the  retina.  In  miliary  tuberculosis 
of  the  choroid  the  overlying  retina  is  clear,  and  the  growth 
is,  for  the  most  part,  deeply  seated.  Fig.  7S.  After  very 
severe  choroiditis,  or  extensive  hemorrhage,  absorption  is 
often  incomplete ;  we  find  then,  in  addition  to  atrophy, 
gray  or  white  patches,  or  lines,  which,  in  pattern  and  appear- 
ance, remind  us  of  keloid  scars  in  the  skin,  or  of  patches 
and  lines  of  old  thickening  on  serous  membranes. 

Very  characteristic  changes  are  seen  after  rupture  of  the 
choroid  from  sudden  stretching  caused  by  blows  on  the 
front  of  the  eye.     These  ruptures,  always  situated  in  the 

Fig.  74. 


Ruptures  of  choroid.     (Wecker.) 

central  region,  occur  in  the  form  of  long  tapering  lines  of 
atrophy,  usually  curved  toward  the  disc,  and  sometimes 
branched.  Fig.  74  ;  their  borders  are  often  pigmented.  If 
seen  soon  after  the  blow  the  rent  is  more  or  less  hidden  by 
blood,  and  the  retina  over  it  is  hazy. 

The  pathological  condition  known  as  "colloid  disease" 
of  the  choroid  consists  in  the  growth  of  very  small  nodules, 
soft  at  first,  afterward  becoming  bard  like  glass,  from  the 

10 


218  DISEASES     OF     THE     CHOROID. 

thin  lamina  el  a  slica, which  lies  between  the  pigment  epithe- 
lium and  chorio-capillaris.  It  is  common  in  eyes  excised 
for  old  inflammatory  mischief,  and  in  partial  atrophy  after 
choroiditis,  Fig.  75.      But  little  is  known  of  its  ophthalmo- 

FiG.  75. 


Partial  atrophy  after  «-yphilitic  choroiditis.  Minute  growths  from 
inner  surface  of  choroid,  showing  how  they  disturb  the  outerlayers  of 
the  retina.     X  60. 

scopic  equivalent  or  its  clinical  characters.  Probably  it 
may  result  from  various  forms  of  choroiditis,  and  may  also 
be  a  natural  senile  change. 

Hemorrhage  from  the  choroidal  vessels  is  not  so  often 
recognized  as  from  those  of  the  retina,  but  may  be  seen 
sometimes,  especially  in  old  people  and  in  highly  myopic 
eyes.  The  patches  are  more  rounded  than  retinal  hemor- 
rhage, and  we  can  sometimes  recognize  the  striation  of  the 
overlying  retina.  Occasionally  they  are  of  immense  size. 
Patches  of  atrophy  may  follow. 

Clinical  Forms  of  Choroidal  Disease. 

(1.)  Numerous  discrete  patches  of  choroidal  atrophy, 
sometimes  complete,  as  if  a  round  bit  had  been  punched 
out,  in  others  incomplete,  though  equally  round  and  w^ell 
defined,  are  scattered  in  different  parts  of  the  fundus,  but 
are  most  abundant  toward  the  periphery  ;  or,  if  scanty,  are 
found  only  in  the  latter  situation.  They  are  more  or  less 
pigmented,  unless  the  patient's  complexion  is  extremely 
fair,  Figs.  70,  c,  and  71. 


CLINICAL    FORMS    OF    DISEASE.  219 

(2.)  The  disease  has  the  same  distribution,  but  the 
patches  are  confluent ;  or  large  areas  of  incomplete  atrophy, 
passing  by  not  very  well  defined  boundaries  into  the 
healthy  choroid  around,  are  interspersed  with  a  certain 
number  of  separate  patches ;  or  without  separate  patches 
there  may  be  a  widely  spread  superficial  atrophy  with 
pigmentation.     Fig.  TO,  a  and  h. 

These  two  types  of  choroiditis  disseminata  run  into  one 
another,  different  names  being  used  by  authors  to  indicate 
topographical  varieties.  Generally  both  eyes  are  affected, 
though  unequally  ;  but  in  some  cases  one  eye  escapes. 
The  retina  and  disc  often  show  signs  of  past  or  present  in- 
flammation. 

Syphilis  is  by  far  the  most  frequent  cause  of  symmetrical 
disseminated  choroiditis.  The  choroiditis  begins  from  one 
to  three  years  after  the  primary  disease,  whether  this  be 
acquired  or  inherited  ;  occasionally  at  a  later  period. 

The  discrete  variety.  Fig.  70,  c,where  the  patches,  though 
usually  involving  the  whole  thickness  of  the  choroid,  are 
not  connected  by  areas  of  superficial  change,  is  the  least 
serious  form,  unless  the  patches  are  very  abundant.  A 
moderate  number  of  such  patches  confined  to  the  peri- 
phery cause  no  appreciable  damage  to  sight.  The  more 
superficial  and  widely-spread  varieties,  in  which  the  retina 
and  disc  are  inflamed  from  the  first,  are  far  more  serious. 
The  capillary  layer  of  the  choroid  seldom  again  becomes 
healthy,  and  with  its  atrophy,  even  if  the  deeper  vessels  be 
not  much  changed,  the  retina  suffers,  passing  into  slowly 
progressive  atrophy.  The  retina  often  becomes  pigmented, 
Fig.  81,  its  bloodvessels  extremely  narrowed,  and  the  disc 
passes  into  a  peculiar  hazy  yellowish  atrophy,  "waxy 
disc,"  Hutchinson — ''  choroiditic  atrophy,"  Gowers.  The 
appearances  may  closely  imitate  those  in  true  retinitis  pig- 
mentosa, and  the  patient,  as  in  that  disease,  often  suffers 
from  marked  night-blindness.     Such  patients  continue  to 


220  DISEASES    OF    THE     CHOROID. 

get  slowly  worse  for  many  years,  and  may  become  nearly 
blind. 

Syphilitic  choroiditis  generally  gives  rise,  at  an  early 
date,  to  opacities  in  the  vitreous  ;  these  either  form  large, 
easily  seen,  slowly  floating  ill-defined  clouds,  or  are  so 
minute  and  numerous  as  to  cause  a  diffuse  and  somewhat 
dense  haziness,  "dust-like  opacities,"  Forster.  (Chap. 
XYI.)  Some  of  the  larger  ones  may  be  permanent.  In 
the  advanced  stages,  as  in  true  retinitis  pigmentosa,  pos- 
terior polar  cataract  is  sometimes  developed. 

There  are  no  constant  differences  between  choroiditis  in 
acquired  and  in  inherited  syphilis;  in  many  cases  it  would 
be  impossible  to  guess,  from  the  ophthalmoscopic  changes, 
with  which  form  of  the  disease  we  had  to  do.  But  there 
is,  on  the  whole,  a  greater  tendency  toward  pigmentation 
in  the  choroiditis  of  hereditary  than  in  that  of  acquired 
syphilis,  and  this  applies  both  to  the  choroidal  patches 
and  to  the  subsequent  retinal  pigmentation. 

In  the  treatment  of  syphilitic  choroiditis  we  rely  almost 
entirely  on  the  constitutional  remedies  for  syphilis — mer- 
cury and  iodide  of  potassium.  In  cases  which  are  treated 
early,  sight  is  much  benefited,  and  the  visible  exudations 
quickly  melt  away  under  mercury ;  but  I  believe  that  even 
in  these  complete  restitution  seldom  takes  place,  the  nutri- 
tion and  arrangement  of  the  pigment  epithelium  and  bacil- 
lary  layer  of  the  retina  being  quickly  and  permanently 
damaged  by  exudations  into  or  upon  the  chorio-capillaris, 
as  in  Fig.  72.  In  the  later  periods,  when  the  choroid  is 
thinned  by  atrophy,  or  its  inner  surface  roughened  by  little 
outgrowths.  Fig.  75,  or  adhesions  and  cicatricial  contrac- 
tions have  occurred  between  it  and  the  retina,  nothing  can 
be  done.  A  long  mercurial  course  should,  however,  always 
be  tried  if  the  sight  be  still  failing,  even  if  the  changes  all 
look  old ;  for  in  some  cases,  even  of  very  long  standing, 
fresh  failure  takes  place  from  time  to  time,  and  mercury 


CLINICAL    FORMS    OF     DISEASE.  221 

has  a  very  marked  influence.  In  acute  cases  rest  of  the 
eyes  in  a  darkened  room,  and  the  employment  of  the  arti- 
ficial leech  or  of  dry  cupping  at  intervals  of  a  few  days,  for 
some  weeks,  are  useful.  But  it  is  often  difficult  to  insure 
such  functional  rest,  for  the  patients  seldom  have  pain  or 
other  discomfort. 

Disseminated  choroiditis  sometimes  occurs  without  ascer- 
tainable evidence  of  syphilis,  chiefly  about  the  age  of 
puberty.  Such  cases  often  difi'er  in  some  of  their  ophthal- 
moscopic details  from  ordinary  syphilitic  cases,  especially 
in  the  immunity  of  the  retina  and  disc ;  and  also  in  the 
absence  of  tendency  to  recur.  It  is  but  seldom  that  any 
definite  cause,  such  as  exposure  to  bright  light,  can  be 
plausibly  assigned. 

In  choroiditis  from  any  cause  iritis  may  occur. 

(3.)  The  choroidal  disease  is  limited  to  the  central  re- 
gion.    There  are  many  varieties  of  such  localized  change. 

In  myopia  the  elongation  which  occurs  at  the  posterior 
pole  of  the  eye  very  often  causes  atrophy  of  the  choroid 
contiguous  to  the  disc,  and  usually  only  on  the  side  next 
the  yellow  spot  (see  Myopia).  The  term  ''posterior  staphy- 
loma  "  is  applied  to  this  form  of  disease  when  the  eye  is 
myopic,  because  the  atrophy  is  a  sign  of  posterior  bulging 
of  the  sclerotic.  The  term  sclerotico-choroiditis posterior  is 
often  used,  though  we  but  seldom  see  evidence  of  exudative 
changes  or  hemorrhagic  effusions  at  the  fundus  in  myopia. 
A  similar  crescent,  but  seldom  of  great  width,  is  very  com- 
monly seen,  bounding  the  lower  margin  of  the  disc,  in 
astigmatic  eyes  ;  its  widest  part  nearly  always  corresponds 
with  the  direction  of  the  meridian  of  greatest  curvature  of 
the  cornea  (Chap.  XX.).  A  narrow  and  less  conspicuous 
crescent,  or  zone,  of  atrophy  around  the  disc  is  seen  in 
some  other  states,  notably  in  old  persons  and  in  glaucoma, 
Fig.  96.  Separate,  round  patches  of  complete  atrophy 
("  punched-out  patches")  at  the  central  region  may  occur 


222  DISEASES    OF    THE    CHOROID. 

in  myopia  with  the  above-mentioned  staphyloma,  and  must 
not  then  be  ascribed  to  syphilitic  choroiditis ;  in  other 
cases  of  myopia  ill-defined  partial  atrophy  is  seen  about 
the  y.  s.,  sometimes  with  splits  or  lines  running  hori- 
zontally toward  the  disc. 

Central  senile  choroiditis Several  varieties  of  disease 

confined  to  the  region  of  the  y.  s.  and  disc  are  seen,  and 
chiefly  in  old  persons.  A  particularly  striking  and  rather 
rare  form  is  shown  in  Fig.  76.  In  others  a  larger  but  less 
defined  area  is  affected.  Some  of  these  appearances  un- 
doubtedly result  from  large  choroidal  or  retinal  extravasa- 
tions, but  the  origin  of  the  state  shown  in  Fig.  16  is  obscure. 
In  these  areated  forms  the  large,  deep  vessels  are  often 
much  narrowed,  or  even  converted  into  white  lines  and 
devoid  of  blood-column  by  thickening  of  their  coats.  In 
another  form,  Fig.  11,  the  central  region  is  occupied  by  a 
number  of  small,  white  or  yellowish-white  dots,  sometimes 
visible  only  in  the  erect  image.  This  condition  is  very 
peculiar,  and  appears  to  be  almost  stationary ;  the  discs 
are  sometimes  decidedly  pale ;  when  very  abundant  the 
spots  coalesce,  and  some  pigmentation  is  found;  sometimes 
hemorrhages  occur.  The  pathological  anatomy  and  gen- 
eral relations  of  this  disease  are  incompletely  known;  it 
was  first  described  by  Hutchinson  and  Tay,  and  is  tolerably 
common.  It  is  symmetrical  and  the  changes  may  some- 
times be  mistaken  for  a  slight  albuminuric  retinitis.  No 
treatment  seems  to  have  any  influence.  Every  case  of 
immature  cataract  should,  when  possible,  be  examined  for 
central  choroidal  changes. 

(4.)  Anomalous  forms  of  choroidal  disease. — Single, 
large  patches  of  atrophy,  with  pigmentation,  and  not 
located  in  any  particular  part,  are  occasionally  met  with. 
Probably  some  of  these  have  followed  the  absorption  of 
tubercular  growths  in  the  choroid,  while  others  are  the 
result  of  large  spontaneous  hemorrhages  ;   a  blow  by  a 


CLINICAL     FORMS     OF     DISEASE.  223 

Fig.  76. 


Central  choroiditis.     (Weeker  and  Jaeger.) 
Fig.  77. 


■^ 

V 

K,i  L<!^ 

- 

-^k 

W'-^^x'^'^'l^         ''" 

f  1 

i/^JV^ 

~~"  — 

>y   m 

^^K                \H-          ~^ 

- 

W  jfl| 

^^ 

M 

Central  guttate  senile  choroiditis. 

blunt  object  on  the  sclerotic  causing  local  bleeding,  or  in- 
flammation and  subsequent  atrophy,  may  account  for  such 


224  DISEASES     OF     THE     CHOROID. 

a  patch  at  the  anterior  part  of  the  fundus.  Single  large 
patches  of  exudation  are  also  met  with,  and  are,  perhaps, 
tubercular.  Choroidal  disease  in  disseminated  patches 
seems  sometimes  to  depend  upon  numerous  scattered  hem- 
orrhages into  the  choroid,  which  may  occur  at  different 
dates,  and  which  lead  to  patches  of  partial  atrophy  with 
pigmentation.  The  local  cause  of  such  hemorrhages  is 
obscure;  the  disease  may  occur  in  one  eye  or  both,  and  in 
young  adults  of  either  sex.  It  may  perhaps  be  called 
hemorrhagic  choroiditis  (compare  Chapter  XYI.).  Al- 
though the  changes  produced  are  very  gross,  some  of  these 
patients  regain  almost  perfect  sight,  a  fact,  perhaps,  point- 
ing to  the  deep  layers  of  the  choroid  as  the  seat  of  disease. 
It  is  possible  that  over-use  of  the  eyes  or  exposure  to  great 
heat  or  glare  sometimes  causes  choroiditis. 

Single  spots  of  choroidal  atrophy,  especially  toward  the 
periphery,  should,  no  less  than  abundant  changes,  always 
excite  grave  suspicion  of  former  syphilis,  and  often  furnish 
valuable  corroborative  evidence  of  that  disease.  The  peri- 
phery cannot  be  fully  examined  unless  the  pupil  be  widely 
dilated.  A  few  small  scattered  spots  of  black  pigment  on 
the  choroid  or  in  the  retina,  without  evidence  of  atrophy 
of  the  choroid,  often  indicate  former  hemorrhages.  Such 
spots  are  seen  after  recovery  from  albuminuric  retinitis 
with  hemorrhages,  after  blows  on  the  eye,  and  sometimes 
without  any  relevant  history. 

Congestion  of  the  choroid  is  not  commonly  recognizable 
by  the  ophthalmoscope.  That  active  congestion  does  occur 
is  certain,  and  it  would  seem  that  myopic  eyes  are  espe- 
cially liable  to  it,  particularly  when  over-used  or  exposed 
to  bright  light  and  great  heat.  Serious  hemorrhage  may 
undoubtedly  be  excited  under  such  circumstances.  In 
conditions  of  extreme  anaemia  the  whole  choroid  becomes 
unmistakably  pale. 

Coloboma  of  the  choroid,  congenital  deficiency  of  the 


CLINICAL     FORMS     OF     DISEASE.  225 

lower  part,  is  shown  ophthalmoscopically  by  a  large  surface 
of  exposed  sclerotic,  often  embracing  the  disc,  which  is 
then  much  altered  in  form,  and  may  be  hardly  recogniz- 
able, and  extending  downward  to  the  periphery,  where  it 
often  narrows  to  a  mere  line  or  chink.  The  surface  of  the 
sclerotic,  as  judged  by  the  course  of  the  retinal  vessels,  is 
often  very  irregular  from  bulging  on  its  floor  backward. 
The  coloboma  is  occasionally  limited  to  the  part  around 
the  nerve,  or  may  form  a  separate  patch.  Coloboma  of 
the  choroid  is  often  seen  without  coloboma  of  the  iris,  and 
when  both  exist  a  bridge  of  choroidal  tissue  generally  sep- 
arates them  in  the  region  of  the  ciliary  body.  Cases  of 
so-called  coloboma  of  the  choroid  at  the  yellow  spot  are 
probably  examples  of  severe  fcetal  or  infantile  inflamma- 
tion of  that  part. 

Albinism  is  accompanied  by  congenital  absence  of  pig- 
ment in  the  cells  of  the  epithelium  and  stroma  of  the 
whole  uveal  tract  (choroid,  ciliary  processes,  and  iris). 
The  pupil  looks  pink,  because  the  fundus  is  lighted  to  a 
great  extent  indirectly  through  the  sclerotic.  Sight  is 
always  defective,  and  the  eyes  photophobic  and  usually 
oscillating.  Many  almost  albinotic  children  become  mod- 
erately pigmented  as  they  grow  up. 


10* 


CHAPTER   XIII. 

DISEASES    OF    THE  RETINA. 

Of  the  many  morbid  changes  to  which  the  retina  is 
subject,  some  begin  and  end  in  this  membrane,  such  as 
albuminuric  retinitis  and  many  forms  of  retinal  hemor- 
rhage ;  in  others  the  retina  takes  part  in  changes  which 
begin  in  the  optic  nerve  (neuro-retinitis),  or  in  the  choroid 
(choroido-retinitis);  very  serious  lesions  also  occur  from 
embolism  or  thrombosis  of  the  central  retinal  vessels.  The 
retina  may  be  separated  ("detached")  from  the  choroid  by 
serous  fluid  or  blood.  The  retina  may  also  be  the  seat 
of  malignant  growth  (glioma),  and  probably  of  tubercular 
inflammation. 

In  health  the  human  retina  is  so  nearly  transparent  as  to 
be  almost  invisible  by  the  ophthalmoscope  during  life,  or 
to  the  naked  eye  if  examined  immediately  after  excision. 
We  see  the  retinal  bloodvessels,  but  the  retina  itself,  as  a 
rule,  we  do  not  see.  The  main  bloodvessels  are  derived 
from  the  arteria  and  vena  centralis,  which  enter  the  outer 
side  of  the  optic  nerve,  about  6  mm.  behind  the  eye;  the 
veins  and  arteries  are  generally  in  pairs,  the  veins  not 
being  more  immerous  than  the  arteries  ;  all  pass  from  or  to 
the  optic  disc.  Fig.  34.  At  the  disc  anastomoses,  chiefly 
capillary,  are  formed  between  the  vessels  of  the  retina  and 
those  cf  the  choroid  and  sclerotic.  As  no  other  anastomoses 
are  formed  by  the  vessels  of  the  retina,  the  retinal  circula- 
tion beyond  the  disc  is  terminal ;  and  further,  as  the  ves- 
sels branch dichotomously,  and  the  branches  anastomose 
only   by  means  of  their  capillaries,  the  circulation  of  each 


DISEASES     OF     THE     RETINA. 


227 


considerable  branch  is  terminal  also.  The  capillaries, 
which  are  not  visible  by  the  ophthalmoscope,  are  narrower 
than  those  of  the  choroid,  and  their  meshes  become  much 
wider  toward  the  anterior  and  less  important  parts  of  the 
retina. 

At  the  3-.  s.,  Fig.  78,  the  only  part  used  for  accurate  sight,  the 
capillaries  are  very  abundant  {compare  Fig.  69) ;  but  at  the  very 
centre  of  this  region, /oueacentraZis,  where  all  the  layers  except 
the  cones  and  outer  granules  are  excessively  thin,  there  are  no 
vessels,  the  capillaries  forming  fine,  close  loops  just  around  it. 
The  nerve-fibres  in  this  part  of  the  retina  are  finer  than  in  other 
parts  ;  the}^  seem  also  to  be  much  more  abundant,  for  Bunge 
has  found  that  in  a  case  of  central  scotoma,  where  only  a  very 
small  part  (^V-th)  of  the  F.  was  lost,  quite  a  large  tract  of  fibres 
(^tli  of  the  whole)  was  atrophied  in  the  optic  nerve.  The  fovea 
centralis  corresponds  to  an  area  at  the  centre  of  F.,  measuring 
onl}'  1^0  iQ  diameter  ;  the  part  recognized  as  the  macula  lutea 
has  an  area,  on  the  F.,  of  about  7--'  (Bunge). 

Fig.  78. 


Bloodvessels  of  human  retina  at  the  yellow  spot  (artiflcial  injection). 
The  central  gap  corresponds  to  the  Fovea  centralis,  a.  Arteries  ;  v. 
Veins ;  n.  Nasal  side  (toward  disc)  ;  T.  temporal  side.  The  meshes  are 
many  times  wider  at  the  periphery  of  the  retina. 

In  children,  especially  those  of  dark  complexion,  a  pecu- 
liar, white,  shifting  reflection,  or  shimmer,  is  often  seen  at 


228  DISK  ASKS     OF     THK     RETINA. 

llje  y.  s.  region,  and  along-  the  course  of  the  principal  ves- 
sels. It  changes  with  every  movement  of  the  mirror,  and 
reminds  one  of  the  shifting  reflection  from  "  watered"  and 
"  shot"  silk.  Around  the  y.  s.  it  takes  the  form  of  a  ring 
or  zone,  and  is  known  as  the  "  halo  round  the  macula." 
When  the  choroid  is  highly  pigmented,  even  if  this  shift- 
ing reflection  be  absent,  the  retina  is  visible  as  a  faint  haze 
over  the  choroid  like  the  "bloom"  on  a  plum.  Under  the 
high  magnifying  power  of  the  erect  image  the  nerve-fibre 
layer  is  often  visible  near  the  disc,  as  a  faintly  marked 
radiating  striation.  The  sheaths  of  the  large  central  ves- 
sels at  their  emergence  from  the  physiological  pit,  p.  72, 
show^  many  variations  in  thickness  and  opacity. 

In  rare  cases  the  medullary  sheath  of  the  optic  nerve- 
fibres,  w^hich  should  cease  at  the  lamina  cribrosa,  is  continued 
through  the  disc  into  the  retina,  and  causes  the  ophthalmo- 
scopic appearance  known  as  "opaque  nerve-fibres."  This 
congenital  peculiarity  may  affect  the  nerve-fibres  of  the 
whole  circumference  of  the  disc,  or  only  a  patch  or  tuft  of 
the  fibres;  it  may  only  just  overleap  the  edge  of  the  disc 
or  may  extend  far  into  the  retina ;  and  islands  of  similar 
opacity  are  sometimes  seen  in  the  retina  quite  separated 
from  the  disc.  It  is  to  be  particularly  noted  that  the  cen- 
tral part,  physiological  pit,  of  the  disc  is  not  affected,  be- 
cause it  contains  no  nerve-fibres.  The  affected  patch  is  pure 
white,  and  quite  opaque,  its  margin  thins  out  gradually, 
and  is  striated  in  fine  lines,  w^hich  radiate  from  the  disc 
like  carded  cotton-wool ;  the  retinal  vessels  may  be  buried 
in  the  opacity,  or  run  unobscured  on  its  surface,  and  are 
of  normal  size.  The  deep  layers  of  the  affected  parts  of 
the  retina  being  obscured  by  the  opacity,  an  enlargement 
of  the  normal  "  blind  spot"  is  the  result.  One  eye,  or  both, 
may  be  affected.  There  is  seldom  any  difliculty  in  dis- 
tinguishing this  condition  from  opacity  due  to  neuro- 
rtitinitis. 


ophthalmoscopic   signs.  229 

Ophthalmoscopic  Signs  of  Retinal  Disease. 

Congestion. — No  amoimt  of  capillary  congestion,  whether 
passive  or  active,  alters  the  appearance  of  the  retina ;  and 
as  to  the  large  vessels,  it  is  better  to  speak  of  the  arteries 
as  unusually  large  or  tortuous,  or  of  the  veins  as  turgid  or 
tortuous,  than  to  use  the  general  term  congestion.  Capil- 
lary congestion  of  the  optic  disc  may  undoubtedly  be 
recognized,  but  even  here  caution  is  needed,  and  much 
allowance  must  be  made  for  differences  of  contrast  depend- 
ing on  variations  in  the  tint  of  the  choroid,  for  the  patient's 
health  and  age,  and  for  the  brightness  of  the  light  used, 
or,  what  is  the  same  thing,  for  the  size  of  the  pupil.  Caution 
is  also  needed  against  drawing  hasty  inferences  from  the 
slight  haziness  of  the  outline  of  the  disc,  which  may  often 
be  seen  in  cases  of  hypermetropia,  and  which  is  certainly 
not  always  morbid. 

The  only  ophthalmoscopic  proof  of  true  retinitis  is  loss  of 
transparency  of  the  retina,  and  two  chief  types  are  soon 
recognized  according  as  the  opacity  is  diffused  or  consists 
chiefly  of  abrupt  spots  and  patches.  Hemorrhages  are 
present  in  many  cases  of  retinitis;  but  they  may  also  occur 
without  either  inflammation  or  oedema.  The  state  of  the 
disc  varies  much,  but  it  seldom  escapes  entirely  in  a  case 
of  extensive  or  prolonged  retinitis.  In  a  large  majority  of 
cases  of  recent  retinitis  the  visible  changes  are  limited  to 
the  central  region,  where  the  retina  is  thickest  and  most 
vascular. 

(1.)  The  lessened  transparency  which  accompanies  dif- 
fused retinitis  simply  dulls  the  red  choroidal  reflex,  and 
the  term  "smoky"  is  fairly  descriptive  of  it.  The  same 
effect  is  given  by  slight  haziness  of  any  of  the  anterior 
media,  but  a  mistake  is  excusable  only  where  there  is  dif- 
fused mistiness  of  the  vitreous  from  opacities  which  are  too 
small  to  be  easily  distinguished,  and  the  difficulty  is  then 


230 


DISEASES     OF     THE     RETINA. 


increased  because  this  very  condition  of  the  vitreous  often 
coexists  with  retinitis.  A  comparison  of  the  erect  and  in- 
verted images  is  often  useful,  for  if  the  diffused  haze  noticed 
by  indirect  examination  be  caused  by  retinitis,  the  direct 
examination  will  often  resolve  what  seemed  a  uniform 
haze  into  a  w^ell-marked  spotting  or  streaking.  When  the 
change  is  pronounced  enough  to  cause  a  decidedly  white 
haze  of  the  retina,  there  is  no  longer  any  doubt.  The 
retinal  arteries  and  veins  are  sometimes  enlarged  and  tor- 
tuous in  retinitis,  and  in  severe  cases  they  are  generally 
obscured  in  some  part  of  their  course.  These  forms  of 
uniformly  diffused  retinitis  are  usually  caused  either  by 
syphilis,  embolism,  or  thrombosis. 

(2.)  Near  the  y.  s.  a  number  of  small,  intensely  white, 
rounded  spots  are  seen,  Fig.  79,  either  quite  discrete  or 

Fig.  79. 


Renal  retinitis  at  a  late  stage.     (Weaker  and  Jaeger.) 


partly  confluent.     When  very  abundant  and  confluent  they 
form  large,  abruptly  outlined  patches,  with  irregular  bor- 


OPHTHALMOSCOPIC     SIGNS. 


231 


ders,  some  parts  of  these  patches  being  striated,  others 
stippled. 

(3.)  A  number  of  separate  patches  are  scattered  about 
the  central  region,  but  without  special  reference  to  the  y.  s. 
They  are  of  irregular  shape,  white  or  pale  buff,  and  some- 
times striated,  Fig.  80;  they  are  easily  distinguished  from 

Fig.  80. 


Recent  severe  retinitis  in  renal  disease.     (Gowers.) 


patches  of  choroidal  atrophy  by  their  color,  the  compara- 
tive softness  of  their  outlines,  and  the  absence  of  pigmen- 
tation. 

In  types  2  and  3  some  hemorrhages  are  usually 
present ;  the  retina  generally  may  be  clear,  but  more  often 
there  is  diffused  haze  and  evidence  of  swelling.  The  hem- 
orrhages may  be  so  numerous  and  large  as  to  form  the 
chief  feature,  and  then  the  retinal  veins  will  be  very  tor- 
tuous and  dilated. 

Forms  2  and  3,  which  nearly  always  affect  both  eyes, 
are  generally  associated  with  renal  disease,  but  in  rare 


232  DISEASES     OF     THE     RETIiNA. 

cases  similar  changes  are  caused  by  cerebral  disease  and 
other  conditions. 

(4.)  Rarely  a  single  large  patch  or  area  of  white  opacity 
is  seen  with  softened,  ill-defined  edges,  any  retinal  vessels 
that  may  cross  it  being  obscured.  Such  a  patch  of  retinitis 
is  usually  caused  either  by  subjacent  choroiditis,  or  by  local 
phlebitis  or  thrombosis. 

Hemorrhage  into  (or  beneath)  the  retina  is  known  by  its 
color,  which  is  darker  than  that  of  an  ordinary  choroid, 
but  redder  and  lighter  than  that  of  a  very  dark  choroid. 
Blood  may  be  effused  into  any  of  the  retinal  layers,  and 
the  shape  of  the  blood  patches  is  mainly  determined  by 
their  position.  When  effused  into  the  nerve-fibre  layer,  or 
confined  by  the  sheath  of  a  large  vessel,  the  extravasation 
takes  a  linear  or  streaked  form  and  structure,  following  the 
direction  of  the  nerve-fibres  ;  extravasations  in  the  deeper 
layers  are  rounded.  Yery  large  hemorrhages,  many  times 
as  large  as  the  disc,  sometimes  occur  near  the  yellow  spot, 
and  probably  all  the  layers  then  become  infiltrated,  while 
sometimes  the  blood  ruptures  the  anterior  limiting  mem- 
brane of  the  retina  and  passes  into  the  vitreous. 

Retinal  hemorrhages  may  be  large  or  small,  single  or 
multiple ;  limited  to  the  central  region  or  scattered  in  all 
parts  ;  linear,  streaky,  or  flame-shaped,  punctate  or  blotchy ; 
they  may  lie  alongside  large  vessels,  or  have  no  apparent 
relation  to  them.  The  hemorrhage  may,  as  already  men- 
tioned, be  the  primary  change,  or  may  only  form  part  of 
a  retinitis  or  papillo-retinitis.  A  hemorrhage  which  is 
mottled  and  of  dark,  dull  color,  is  generally  old.  The  rate 
of  absorption  varies  very  much  ;  hemorrhage  after  a  blow 
is  very  quickly  absorbed,  while  effusions  caused  by  the  rup- 
ture of  diseased  vessels  in  old  people,  or  accompanying 
retinitis  from  constitutional  causes,  often  last  for  months, 
and  leave  permanent  traces. 


OPHTHALMOSCOPIC     SIGNS.  233 

Pigmentation  of  the  retina  has  been  referred  to  in  con- 
nection with  choroiditis.  TS^henever  pigment  in  the  fundus 
forms  long,  sharply-defined  lines,  or  is  arranged  in  a  mossy, 
lace-like,  or  reticulated  pattern,  we  may  safely  infer  that  it 
is  situated  in  the  retina,  and  generally  that  it  lies  along  the 
sheaths  of  the  retinal  vessels — compare  Fig.  81  with  Fig. 
78.     Pigment  in  or  on  the  choroid  never  takes  such  a  pat- 

FiG.  81. 


Study  of  pigment  in  tlie  retina  in  a  specimen  of  secondary  retinitis 
pigmentosa,  seen  from  the  inner  (vitreous)  surface. 

tern,  being  usually  in  blotches  or  rings.  The  two  types, 
however,  are  often  mingled  in  cases  of  choroiditis  with 
secondary  affection  of  the  retina  ;  indeed,  whenever  we 
decide  that  the  retina  is  pigmented,  the  choroid  must  be 
carefully  examined  for  evidences  of  former  choroiditis. 

Spots  of  pigment  may  be  left  after  the  absorption  of  reti- 
nal hemorrhages.  Such  spots  can  generalh'  be  distin- 
guished from  those  following  choroiditis  by  their  more 
uniform  appearance  and  by  thea))senceof  signs  of  choroidal 
atrophy. 

Atrophy  of  the  retina,  of  which  pigmentation  of  the 
retina,  when  present,  is  always  a  sign,  has  for  its  most  con- 
stant indication  a  marked  shrinking  of  the  retinal  blood- 
vessels with  thickening  of  their  coats.  When  the  atrophy 
follows  a  retinitis  or  choroido-retinitis,  retinitis  pigmentosa, 
syphilitic  choroido-retinitis,  etc.,  all  the  layers  are  involved, 
and  the  outer  layers,  those  nearest  the  choroid,  earlier  than 
the  inner ;  but  when  it  is  secondary  to  disease  of  the  optic 
nerve,  optic  neuritis,  progressive  atrophy,  and  glaucoma, 
only  the  layers  of  nerve-fibres  and  ganglion  cells  are  atro- 


234  DISEASES     OF     THE     RETINA. 

phied,  the  outer  layers  bcinti;-  found  perfect,  even  after 
many  years.  A  retina  atrophied  after  retinitis  often  does 
not  re<i:ain  perfect  transparency,  and  if  there  have  been 
choroiditis  the  retina  remains  especially  hazy  in  the  parts 
where  this  has  been  most  severe. 

The  disc  after  severe  retinitis  or  choroido-retinitis  always 
passes  into  atrophy,  often  of  peculiar  appearance,  being 
pale,  hazy,  homogeneous-looking,  and  with  a  yellowish  or 
brownish  tint. 

Detachment  (separation)  of  the  retina As  there  is  no 

continuity  of  structure  between  the  choroid  and  retina,  the 
two  may  be  easily  separated  by  effusion  of  blood  or  serous 
fluid,  the  result  of  injury  or  disease,  by  morbid  growths, 
and  by  the  traction  of  fibrous  cords  in  the  vitreous.  Such 
fibrous  bands  and  strings  develop  in  the  vitreous  in  some 
cases  of  irido-cyclitis,  and  perhaps  in  myopic  eyes,  without 
signs  of  inflammation.  Occasionally  rents  may  be  seen  in 
the  separated  retina.  It  has  been  suggested  that  such  rents 
occurring  whilst  the  retina  was  still  in  situ  might  initiate 
the  detachment  by  allowing  the  intrusion  of  vitreous  be- 
tween the  retina  and  choroid ;  and  this  explanation  may 
possibly  hold  good  in  very  myopic  eyes.  The  retina  is 
separated  at  the  expense  of  the  vitreous,  which  is  propor- 
tionately absorbed,  but  always  remains  attached  at  the  disc 
and  ora  serrata,  unless  as  the  result  of  wound  or  great  vio- 
lence. The  depth,  area,  and  situation  of  the  detachment 
are  subject  to  much  variety.  Fig.  82  shows  a  diagram- 
matic section  of  an  eye  in  which  the  lower  part  of  the 
retina  is  separated.  The  pigment  epithelium  always  re- 
mains on  the  choroid. 

The  separated  portion  is  usually  far  within  the  focal 
length  of  the  eye  ;  its  erect  image  is,  therefore,  very  easily 
visible  by  the  direct  method,  when  it  appears  as  a  gray  or 
whitish  reflexion  in  some  part  of  the  field,  the  remainder 
being  of  the  natural  red  color;  the  detached  part  is  gray 


OPHTHALMOSCOPIC     SIGNS.  235 

or  whitish,  because  the  retina  has  become  opaque.  With 
care  we  can  accurately  focus  the  surface  of  the  gray  reflec- 
tion, see  that  it  is  folded,  and  see  one  or  more  retinal  vessels 
meandering-  upon  it  in  a  tortuous  course ;  they  appear  small 

Fig.  82.  Fig.  83. 


Section  of  eye  with  partial  de-  Ophthalmoscopic  appearance  of 

tachment  of  retina.  detached    retina     (erect    image). 

(After  Wecker  and  Jaeger.) 

and  of  dark  color.  If  the  separation  be  deep  the  outline 
of  its  more  prominent  folds,  Fig.  83,  can  be  seen  standing- 
out  sharply  against  the  red  background,  and  in  some  cases 
the  folds  flap  about  when  the  eye  is  quickly  moved.  In 
extreme  cases  we  can  see  the  detached  part  by  focal  light. 
When  the  detachment  is  recent,  especially  if  shallow,  the 
choroidal  red  is  still  seen  through  it ;  the  diagnosis  then 
rests  on  the  observation  of  whether  the  vessels  in  any  part 
become  darker,  smaller,  and  more  tortuous,  and  upon 
ophthalmoscopic  estimation  of  the  refraction  of  the  retinal 
vessels  at  different  parts  of  the  fundus,  for  the  detached 
part  will  be  much  more  hypermetropic  than  the  rest.  In 
very  high  myopia  a  shallow  detachment  may  still  lie  behind 
the  principal  focus,  and  therefore  not  yield  an  erect  image 
without  a  suitable  concave  lens ;  in  such  a  case  and  in 
others  where  minute  rucks  or  folds  of  detachment  are 
present,  examination  by  the  indirect  method  leads  to  a 
right  diagnosis ;  the  image  of  the  detached  portion  is  not 


236  DISEASES     OF     THE     RETINA. 

in  focus  at  the  same  moment  as  its  surrounding  parts,  'paral- 
lactic movement^  is  obtained,  and  the  vessels  are  tortuous. 
Deep  and  extensive  detachment  is  often  associated  with 
opacities  in  the  vitreous  or  lens,  or  with  iritic  adhesions; 
and  any  of  these  conditions  interfere  with  the  conclusive 
application  of  the  above  tests.  In  some  cases  of  detach- 
ment, large  patches  and  streaks  of  choroidal  disease  are  to 
be  found.  The  treatment  of  detachment  of  the  retina  is 
very  unsatisfactory,  improvement  if  obtained  being  seldom 
permanent,  even  when  treatment  is  undertaken  soon  after 
the  detachment  has  occurred.  Puncture  of  the  sclerotic 
over  the  detachment  is  occasionally  followed  by  marked 
improvement,  and  the  result  is  said  to  be  better  if  the  scle- 
rotic be  laid  bare  by  dissecting  up  the  conjunctiva  before 
the  puncture,  and  if  the  puncture  be  rather  broad,  about 
2  to  4  mm.,  the  subretinal  fluid  rapidly  drains  away.  The 
conjunctival  wound  should  be  sutured.  Profuse  sweating 
and  salivation,  induced  by  pilocarpine  (F.  38),  have  been 
recommended  in  recent  cases.  Mere  rest  in  bed  for  some 
days  in  a  subdued  light  and  with  the  eyes  tied  up,  is  often 
followed  for  a  time  by  decided  improvement  of  sight.  The 
best  results  seem  to  have  been  obtained  by  this  means  com- 
bined with  scleral  puncture,  in  recent  cases. 

Clinical  Forms  of  Retinal  Disease. 

The  symptoms  of  retinal  disease  relate  only  to  the  failure 
of  sight  which  they  cause,  and  this  may  be  either  general, 
or  confined  to  a  part  of  the  field,  according  to  the  nature 
of  the  case.  Neither  photophobia  nor  pain  occurs  in 
uncomplicated  retinitis. 

1  On  closing  one  eye  and  viewing  two  objects,  one  beyond  the  other, 
but  in  the  same  line,  one  object  seems  to  move  over  the  other  when  the 
head  is  moved  from  side  to  side. 


CLINICAL    FORMS    OF     RETINAL    DISEASE.      237 

Syphilitic  retinitis  is  generally  associated  with,  and  sec- 
ondary to,  choroiditis,  but  the  retinitis  may  be  primary. 
The  vitreous  in  this  disease,  as  in  syphilitic  choroiditis,  is 
often  hazy,  and  the  opacities  are  sometimes  seated  deeply, 
just  in  front  of  the  retina.  The  changes  are  those  of  diffuse 
retinitis,  with  slight  "smoky  "  haze,  often  confined  to  the 
region  of  the  yellow  spot  or  disc  ;  but  in  bad  cases  the  haze 
passes  into  a  whiter  mistiness,  and  extends  over  a  much 
larger  region  ;  sometimes  long  branching  streaks  or  bands 
of  dense  opacity  are  met  with,  and  hemorrhages  may  occur. 
The  disc  is  always  hazy,  and  at  first  too  red,  while  the  reti- 
nal vessels,  both  arteries  and  veins,  are  somewhat  turgid 
and  tortuous;  rarely  the  disc  becomes  opaque  and  swollen. 
At  a  late  period,  in  unfavorable  cases,  the  vessels  shrink 
slowly,  almost  to  threads,  the  retina  often  becomes  pig- 
mented at  the  periphery,  and  the  pigmented  epithelium 
disappears. 

Syphilitic  retinitis  is  one  of  the  secondary  symptoms, 
seldom  setting  in  earlier  than  six  or  later  than  eighteen 
months  after  the  primary  disease.  It  occurs  in  congenital 
as  well  as  in  acquired  syphilis.  It  generally  attacks  both 
eyes,  though  often  with  an  interval.  Its  onset  is  often 
rapid,  as  judged  by  its  chief  symptom,  failure  of  sight,  and 
it  may  be  stated  that  as  a  rule  the  degree  of  amblyopia  is 
much  higher  than  would  be  expected  from  the  ophthal- 
moscopic changes.  Night-blindness  is  often  a  pronounced 
symptom.  Its  course  is  chronic,  seldom  lasting  less  than 
several  months,  and  it  shows  a  remarkable  tendency  for 
many  months  to  repeated  and  rapid  exacerbations  after 
temporary  recoveries,  but  with  a  tendency  to  get  worse 
rather  than  permanently  better.  Amongst  the  early  symp- 
toms is  often  a  "flickering"  and  micropsia  ;  these  with  the 
history  of  variations  lasting  for  a  few  days,  and  of  marked 
night-blindness,  often  lead  to  a  correct  surmise  before  oph- 
thalmoscopic examination.     There  is,   however,  nothing 


238  DISEASES     OF     THE     RETINA. 

pathognomonic  in  any  of  the  symptoms.  An  annular 
defect  in  the  visual  field,  "ring  scotoma,"  may  often  be 
found  if  sought ;  in  the  late  stages  the  field  is  contracted. 

Mercury  produces  most  marked  benefit,  and  when  used 
early  it  permanently  cures  a  large  proportion  of  the  cases; 
but  in  a  number  of  cases,  perhaps  in  those  where  there  is 
most  choroiditis,  the  disease  goes  slowly  from  bad  to  worse 
for  several  years  in  spite  of  very  prolonged  mercurial  treat- 
ment. Of  the  efficacy  of  prolonged  disuse  of  the  eyes  and 
of  local  counter-irritation  or  depletion,  strongly  recom- 
mended by  many  authors,  I  have  had  but  little  experience. 

Albuminuric  retinitis  (papillo-retinitis) The  changes 

are  strongly  marked,  and  so  characteristic  that  it  is  possi- 
ble in  most  cases  to  say  from  an  ophthalmoscopic  examina- 
tion alone  that  the  patient  is  suffering  from  kidney  disease. 

The  earliest  change,  the  stage  of  oedema  and  exudation, 
is  a  general  haze  of  grayish  tint  in  the  central  region  of 
the  retina,  mostly  with  some  hemorrhages  and  soft-edged 
whitish  patches,  and  with  or  without  haze  and  swelling  of 
the  disc.  In  this  stage  the  sight  is  often  unimpaired  and 
so  the  cases  are  seldom  seen  by  ophthalmic  surgeons  till  a 
few  weeks  later,  when  the  translucent,  probably  albumi- 
nous exudations  in  the  swollen  retina  have  passed  into  a 
state  of  fatty  or  fibrinous  degeneration,  a  change  which 
affects  both  the  nerve-fibres  and  connective  tissue. 

In  this,  the  second  stage,  we  find  a  number  of  pure  white 
dots,  spots,  or  patches  in  the  hazy  region,  and  especially 
grouped  around  the  yellow  spot.  Their  peculiarity  is  their 
sharp  definition  and  pure,  opaque,  white  color;  indeed, 
when  small  and  round  they  are  almost  glistening.  When 
not  very  numerous  theyare  generally  confined  to  the  yellow- 
spot  region,  from  which  they  show  a  tendency  to  radiate  in 
lines.  Fig.  79;  when  very  small  and  scanty  they  may  be 
overlooked,  unless  we  examine  the  erect  image  ;  but  fre- 
quently large  patches  are  formed  b}'  the  confluence  of  small 


CLINICAL     FORMS     OF     RETINAL    DISEASE.       239 

spots,  and  the  borders  of  these  patches  are  striated,  cre- 
nated,  or  spotted.  At  this  stage  the  soft-edged  patches, 
Fig.  80,  have  often  to  a  great  extent  disappeared  or  become 
merged  into  more  general  opacity  of  the  retina ;  the  disc  is 
hazy  and  somewhat  swollen,  especially  just  at  its  margin, 
and  the  retina,  as  judged  by  the  undulations  of  its  vessels, 
and  confirmed  by  post-mortem  examination,  is  much  thick- 
ened. Hemorrhages  are  generally  still  present  and  occa- 
sionally they  constitute  the  most  marked  feature;  they  are 
usually  striated.  Sometimes  an  artery  is  seen  sheathed  by 
a  dense  white  coating.^  In  another  group  papillitis  is  the 
most  marked  change,  though  some  bright  white  retinal  spots 
are  always  to  be  found  by  careful  examination. 

The  usual  tendency  is  toward  subsidence  of  the  oedema 
and  absorption  of  the  fatty  deposits  and  extravasations, 
generally  with  improvement  of  sight — the  third  stage,  or 
stage  of  absorption  and  atrophy. 

In  the  course  of  several  months  the  white  spots  diminish 
in  size  and  number,  until  only  a  few  very  small  ones  are 
left  near  the  yellow  spot,  with,  perhaps,  some  residual  haze ; 
the  blood-patches  are  slowly  absorbed,  often  leaving  small 
round  pigment  spots,  and  the  retinal  arteries  may  be 
shrunken.  In  cases  of  only  moderate  severity  almost  per- 
fect sight  is  restored.  But  when  the  optic  disc  suffers 
severely,  severe  papillitis,  or  if  the  retinal  disease  be  exces- 
sive and  attended  by  great  oedema,  sight  either  improves 
very  little,  or,  as  the  disc  passes  into  atrophy  and  the  retinal 
vessels  contract,  it  may  sink  to  almost  total  blindness. 
Such  a  condition  may  be  mistaken  for  atrophy  after  cere- 
bral neuritis;  but  the  presence  of  a  few  minute  bright  dots 
or  of  some  superficial  disturbance  of  the  choroid  at  the 
yellow  spot,  or  of  some  scattered  pigment  spots  left  by  ex- 

^  Illustrations  of  this  are  given  in  Gowers'  Medical  Ophthalmoscopy, 
pi.  xii.,  fig.  1,  and  in  Trans.  Ophth.  Soc,  vol.  ii.  pi.  ii. 


240  DISEASES     OF     THE     RKTINA. 

travasations,  will  generally  lead  to  a  correct  inference.  In 
the  cases  attended  by  the  greatest  swelling  and  opacity  of 
retina  and  disc,  death  often  occurs  before  retrogressive 
changes  have  taken  place.  In  extreme  cases  the  retina 
may  become  deeply  detached  from  the  choroid. 

Albuminuric  retinitis  is  almost  invariably  symmetrical, 
but  seldom  quite  equal  in  degree  or  result  in  the  two  eyes. 

The  kidney  disease  in  the  malady  under  consideration  is 
nearly  always  chronic.  The  retinitis  may  occur  in  any 
chronic  nephritis,  and  in  the  albuminuria  of  pregnancy. 
Whatever  be  the  form  of  the  kidney  disease,  the  retinitis 
usually  occurs  with  other  symptoms  of  active  kidney  mis- 
chief, such  as  headache,  vomiting,  loss  of  appetite,  and 
often  anasarca ;  but  occasionally  the  retinitis  is  the  first 
recognizable  sign.  The  quantity  of  albumen  varies  very 
much.  In  the  absence  of  anasarca  the  symptoms  are  often 
put  down  to  "biliousness,"  and  as  in  such  cases  the  failure 
of  sight  is  the  most  troublesome  symptom,  the  ophthalmo- 
scope often  leads  to  the  correct  diagnosis.  A  second  attack 
of  retinitis  sometimes  occurs  in  connection  with  a  relapse 
of  renal  symptoms.  Many  of  the  best  marked  cases  of 
albuminuric  retinitis  occur  in  the  albuminuria  of  preg- 
nancy, and  the  prognosis  for  sight  is  good  in  many  of  these 
if  the  symptoms  come  on  sufficiently  late  in  the  pregnancy 
to  permit  of  the  cause  being  removed  by  the  induction  of 
artificial  labor  ;  but  some  of  them  (probably  cases  of  old 
kidney  disease)  do  very  badly,  and  pass  into  atrophy  of 
the  nerves. 

Though  the  diagnosis  of  renal  disease,  based  on  the  pres- 
ence of  the  symmetrical  retinal  changes  above  described, 
will  usually  be  verified  by  the  physician,  we  do  unquestion- 
ably now  and  then  meet  with  cases  of  similar  retinitis  in 
which  no  kidney  disease  can  be  clinically  proved.  Trous- 
seau describes  several  cases  of  this  sort  in  which  albumen 


CLINICAL    FORMS     OF     RETINAL     DISEASE.       241 

appeared  later.^  Such  cases  iieed  further  attention.  The 
cases  of  cerebral  neuro-retinitis  mentioned  at  p.  255,  and 
rare  cases  of  retinitis,  exactly  like  renal  retinitis,  but  con- 
fined to  one  eye,  have  also  to  be  allowed  for.  Retinal 
changes  more  or  less  like  those  above  described  are  also 
found  in  other  chronic  general  diseases,  e.  g.,  diabetes,  per- 
nicious amemia,  and  leucocythaemia  (Chapter  XXIII.). 

The  term  retinitiH  hsemorrhagica  has  been  given  to  cases 
characterized  by  very  numerous  linear  or  flame-shaped 
retinal  hemorrhages,  chiefly  of  small  size,  all  over  the 
fundus,  sometimes  with  extreme  venous  engorgement  and 
retinal  oedema,  but  in  other  cases  without  these  features. 
It  usually  occurs  in  only  one  eye  at  a  time,  and  comes  on 
rapidly.  The  patients  are  often  gouty,  or  the  subjects  of 
disease  of  cardiac  valves,  or  of  the  arterial  system.  Throm- 
bosis of  the  trunk  of  the  vena  centralis  retinae  is  probably 
the  determining  cause  of  the  condition^  when  there  is  much 
venous  distention  and  retinal  oedema;  multiple  disease  of 
minute  retinal  vessels,  when  these  symptoms  are  absent. 
Retinitis  hemorrhagica,  of  whichever  type,  is  not  common. 

Other  cases  are  seen  where  extravasations,  varying  much 
in  size,  number,  and  shape,  are  scattered  in  different  parts 
of  the  fundus  of  one  or  both  eyes.  Some  of  them  are 
probably  allied  to  the  above,  but  often  the  nature  of  the 
case  is  obscure,  or  the  hemorrhages  are  related  to  senile 
degeneration  of  vessels.  Such  cases  have  been  called 
retiniiis  apoplectica. 

Lastly,  in  an  important  group,  a  single  very  large  ex- 
travasation occurs  from  rupture  of  a  large  retinal  vessel, 
probably  an  artery.  The  hemorrhage  is  generally  in  the 
yellow-spot  region  ;  in  process  of  absorption  it  becomes 
mottled,  the  densest  parts  remaining  longest,  and  if  seen  in 

1  Bull,  de  l'H6pital  des  Quatre-vingts,  iv.  4,  173. 

2  Hutchinson  ;  Michel,  Graefe's  Arch.  f.  Ophth.,  xxiv,  2. 

11 


242  DISEASES     OF     THE     RETINA. 

that  condition  for  the  first  time,  the  case  may  be  taken  for 
one  of  multiple  hemorrhages.  These  large  extravasations 
cause  great  defect  of  sight,  which  comes  on  in  an  hour  or 
two,  but  not  with  absolute  suddenness.  Absorption,  in 
the  several  groups  of  cases  just  mentioned,  is  very  slow. 

Hemorrhages  may  occur  from  blows  on  the  eye.  They 
are  usually  small,  and  quickly  absorbed,  difTering  in  the 
latter  respect  very  much  from  the  cases  before  described. 

Embolism  of  the  central  artery  of  the  retina,  or  of  one 
or  more  of  its  main  divisions,  gives  rise  to  a  characteristic 
retinitis,  the  cause  of  which  can  in  most  cases  be  recognized 
at  once  if  it  be  recent ;  whilst  in  old  cases  the  appear- 
ances, taken  with  the  history,  lead  to  a  right  diagnosis. 
Thrombosis  of  the  artery  causes  similar  changes. 

The  leading  symptom  of  embolism  is  the  occurrence  of 
an  instantaneous  defect  of  sight,  which  is  found  on  trial 
to  be  limited  to  one  eye ;  sometimes  the  feeling  is  as  if  one 
eye  had  suddenly  become  "shut,"  the  blindness  being  as 
sudden  as  that  from  quickly  closing  the  lids ;  but  whether 
the  defect  amounts  to  absolute  blindness  or  no,  depends  on 
the  position  and  size  of  the  plug.  Many  of  the  patients 
have  evidence  of  cardiac  disease.  Chorea  has  been  present 
in  a  few.  In  any  case,  owing  to  the  temporary  establish- 
ment of  collateral  circulation  by  the  capillary  anastomoses 
at  the  disc,  the  patient  sometimes  notices  an  improvement 
of  sight  a  few  hours  after  the  occurrence.  This  improve- 
ment, however,  is  but  slight,  the  collateral  channels  being 
quite  insufficient  to  meet  the  demand ;  nor  is  it  often 
permanent,  because  the  retina  suffers  very  quickly  from 
the  almost  complete  stasis,  oedema  and  inflammation  rap- 
idly setting  in  and  leading  to  permanent  damage. 

If  the  case  be  seen  within  a  few  days  of  the  occurrence, 
the  red  reflex  of  the  choroid  around  the  yellow  spot  and 
disc  is  quite  obscured,  or  partially  dulled,  by  a  diffused  and 
uniform  white  mist.     The  opacity  is  greatest  just  around 


CLINICAL    FORMS    OF    RETINAL    DISEASE.      243 

the  centre  of  the  yellow  spot,  where  the  retina  is  very  vas- 
cular, Fig.  78,  and  where  its  cellular  elements,  ganglion 
and  granule  layers,  are  more  abundant  than  elsewhere; 
but  at  the  very  centre  of  the  w^hite  mist  a  small,  round,  red 
spot  is  generally  seen,  so  well  defined  that  it  may  be  mis- 
taken for  a  hemorrhage;  it  represents  the  yo^•ea  centralis, 
where  the  retina  is  so  thin  that  the  choroid  continues  to 
shine  through  it  when  the  surrounding  parts  are  opaque ; 
it  is  spoken  of  by  authors  as  the  ''cherry-red  spot  at  the 
macula  lutea."  This  appearance  is  very  seldom  seen  except 
after  sudden  arrest  of  arterial  blood  supply,  by  embolism 
or  thrombosis  of  the  arteria  centralis  and  perhaps  by 
hemorrhage  into  the  optic  nerve  compressing  the  vessels ; 
and  of  these  causes  embolism  appears  to  be  the  commonest. 
The  haze  surrounds,  and  generally  affects,  the  disc  also, 
which  soon  becomes  very  pale.  The  small  veins  in  the 
yellow-spot  region  often  stand  out  with  great  distinctness, 
being  enlarged  by  stasis,  and  conspicuous  from  contrast 
with  the  white  retina.  Small  hemorrhages  are  often 
present.  The  larger  retinal  vessels,  both  arteries  and  veins, 
are  more  or  less  diminished  at  or  near  the  disc,  the  arteries 
in  the  most  typical  cases  being  reduced  to  mere  threads; 
both  arteries  and  veins  are,  however,  sometimes  observed  to 
increase  in  size  as  they  recede  from  the  disc.  The  arteries, 
however,  are  not  always  extremely  shrunken  in  cases  of 
retinal  embolism,  the  variations  depending  upon  the  posi- 
tion and  size  of  the  plug,  i.  e.,  upon  whether  the  occlusion  is 
complete  or  not.  The  sudden  and  complete  failure  of 
supply  to  a  single  branch  of  a  retinal  artery  is  sometimes 
followed  by  its  emptying  and  shrinking  to  a  white  cord 
almost  immediately.  In  other  cases  the  branch  may  for  a 
time  be  little,  if  at  all,  altered  in  size,  and  yet  its  blood- 
column  be  quite  stagnant,  as  is  proved  by  the  impossibility 
of  producing  pulsation  in  it  by  the  firmest  pressure  on  the 
globe,  whilst  the  other  branches  respond  perfectly  to  this 


244  DISEASES     OF     THE     RETINA. 

test.  Sometimes  this  pressure  test,  which  showed  blockage 
of  some  or  all  branches  shortly  after  the  onset,  again  pro- 
duces pulsation  a  few  days  later  without  visible  evidence  of 
collateral  circulation,  thus  proving  the  re-establishment  of 
the  main  channel. 

In  from  one  to  about  four  weeks  the  cloudiness  clears  oflF, 
and  the  disc  passes  into  moderately  white  atrophy ;  the 
arteries,  or  some  of  them,  according  to  the  position  of  the 
plugging,  are  either  reduced  to  bloodless  w^hite  lines  or 
simply  narrowed. 

Sight  is  almost  always  lost,  or  only  perception  of  large 
objects  retained,  whatever  be  the  final  state  of  the  blood- 
vessels. In  the  rare  eases  where  an  embolus  passes  beyond 
the  disc,  and  is  arrested  in  a  branch  at  some  distance  from 
it,  the  changes  are  confined  to  the  corresponding  sector  of 
the  retina,  and  a  limited  defect  of  the  field  is  the  only  per- 
manent result.  It  is  scarcely  necessary  to  say  that  no 
treatment  can  be  of  any  use  in  cases  of  lasting  occlusion  of 
the  retinal  arteries.  It  will  be  obvious,  too,  that  these 
lesions  will  be  limited  to  one  eye,  though  a  similar  acci- 
dent is  occasionally  seen  afterwards  in  the  other. 

In  a  few  cases  sudden  simultaneous  blindness  of  both  eyes 
has  occurred  with  extremely  diminished  retinal  arteries, 
ischaemia  retinae,  and  iridectomy  has  been  followed  by  re- 
turn of  sight;  lower  tension  causing  re-establishment  of 
circulation.     See  also  Quinine-blindness. 

Retinitis  pigmentosa  is  a  very  slowly  progressive  sym- 
metrical disease,  leading  to  atrophy  of  the  retina,  with 
collection  of  black  pigment  in  its  layers  and  around  its 
bloodvessels,  and  secondary  atrophy  of  the  disc.  The 
earliest  symptom  is  inability  to  see  well  at  night,  or  by 
artificial  light,  night-blindness,  nyctalopia.  Concentric 
contraction  of  the  visual  field  soon  occurs.  Fig.  84.  These 
defects  may  reach  a  high  degree  whilst  central  vision 
remains  excellent  in  bright  daylight.     The  symptoms  are 


CLINICAL     FORMS     OF     RETINAL     DISEASE.       245 

noticed  at  an  earlier  stage  by  patients  in  whom  the  choroid 
is  dark,  and  absorbs  much  light 

Ophthalmoscopic  examination,  where  these  symptoms 
have  been  present  for  some  years,  shows — (1)  at  the  equator 
or  periphery  a  greater  or  less  quantity  of  pigment  arranged 
in  a  reticulated  or  linear  manner,  Fig.  81,  often  with  some 
small,  separate  dots ;  (2)  in  advanced  cases,  evidence  of 
removal  of  the  pigment  epithelium,   but  no  patches  of 

Fig.  84. 


Extreme  concentric  contraction  of  field  of  vision  (R.)  in  a  case  of 
advanced  retinitis  pigmentosa.  The  central  dot  shows  the  fixation 
point.     The  black  shows  the  part  lost. 

choroidal  atrophy  ;  (3)  the  pigment  arranged  in  a  belt, 
which  is  generally  uniform,  the  pattern  being  most  crowded 
at  the  centre,  and  thinning  out  towards  the  borders  of  the 
belt ;  (4)  that  the  changes  are  always  symmetrical,  and  the 
symmetry  very  precise.  These  appearances  are  quite 
characteristic  of  true  retinitis  pigmentosa.  In  addition, 
we  find  (5;  diminution  in  size  of  the  retinal  bloodvessels, 
the  arteries  in  advanced  cases  being  mere  threads  ;  (6)  a 
peculiar  hazy,  yellowish,  "waxy"  pallor  of  the  optic  disc; 
(7)  sometimes  the  pigmented  parts  of  the  retina  are  quite 
hazy ;  (8)  posterior  polar  cataract  and  disease  of  the  vitre- 
ous are  often  present  in  the  later  stages.  The  latter  changes 
(5  to  8),  however,  are  found  in  many  cases  of  late  retinitis 


246  DISEASES    OF    THE     RETINA. 

consecutive  to  choroiditis,  and  are  not  peculiar   to   the 
present  malady. 

The  disease  begins  in  childhood  or  adolescence,  progresses 
slowly  but  surely,  and,  as  a  rule,  ends  in  blindness  some 
time  after  middle  life.  A  few  cases  of  apparently  recent 
origin  are  seen  in  quite  aged  persons,  and  a  few  are  con- 
sidered to  be  truly  congenital.  The  quantity  of  pigment 
visible  by  the  ophthalmoscope  varies  much  in  cases  of 
apparently  equal  duration,  and  is  not  in  direct  relation  to 
the  defect  of  sight ;  cases  even  occur,  which  certainly  be- 
long to  the  same  category,  in  which  no  pigment  is  visible 
during  life,  the  retina  being  merely  hazy,  though  micro- 
scopical examination  reveals  abundance  of  minutely  divided 
pigment  (Poncet).  The  pathogenesis  of  the  disease  is  not 
finally  settled ;  it  is  at  present  doubtful  whether  there  is 
from  the  first  a  slow  sclerosis  of  the  connective-tissue  ele- 
ments of  the  retina,  with  passage  inwards  of  pigment  from 
the  pigment  epithelium,  or  whether  the  disease  begins  in 
the  superficial  layer  of  the  choroid  and  the  pigment  epi- 
thelium. Its  cause  is  obscure.  It  is  undoubtedly  strongly 
heritable,  and  many  high  authorities  believe  that  it  is  really 
produced  by  consanguinity  of  marriage,  either  between  the 
parents  or  near  ancestors  of  the  affected  persons.  Some  of 
its  subjects  are  full  of  mental  and  bodily  vigor ;  but  many 
are  badly  grown,  suffer  from  progressive  deafness,  and  are 
defective  in  intellect.  Although  want  of  education,  as  a 
consequence  of  defective  sight  and  hearing,  may  sometimes 
account  for  this  result,  we  cannot  thus  explain  the  various 
defects  and  diseases  of  the  nervous  system  which  are  not 
infrequently  noticed  in  kinsmen  of  the  patients.  That  the 
subjects  of  this  disease  should  be  discouraged  from  marry- 
ing is  sufficiently  evident.  In  a  few  cases  galvanism  has  been 
followed  by  improvement  both  of  vision  and  visual'  field, 

'  Gunn,  Ophth.  Hosp.  Reports,  x.  161,  and  others. 


CLINICAL    FORMS     OF    RETINAL    DISEASE.       247 

but  no  other  treatmeot  has  any  influence.  Complications 
such  as  cataract  and  myopia  are  not  uncommon,  and  must 
be  treated  on  general  principles. 

It  is  sometimes  very  difficult  to  distinguish  widely-diffused 
and  superficial  choroiditis,  with  pigmentation  of  retina  and 
atrophy  of  the  disc,  from  true  retinitis  pigmentosa.  The 
question  will  generally  relate  to  cause,  as  between  retinitis 
pigmentosa  and  choroido-retinitis  from  syphilis. 

Retinal  disease  from  intense  light. — A  number  of  cases 
have  now  been  observed  in  which  blindness  of  a  small  area 
at  the  centre  of  the  field  has  been  caused  by  staring  at  the 
sun,  usually  during  an  eclipse.  Corresponding  to  this 
functional  defect,  ophthalmoscopic  evidences  of  choroiditis 
or  choroido-retinitis  have  been  found  at  the  yellow  spot. 
The  defect  often  lasts  for  months,  if  not  permanently.^ 
Compare  blindness  from  snow,  electric  light,  etc. 

1  For  accounts  of  cases  and  experiments  on  this  aflfection  see  Lond. 
Med.  Record,  October,  1883 ;  also  Ophthalmic  Review,  April  and  May. 


CHAPTER     XIV. 

DISEASES    OF    THE    UPTIC    NERVE. 

The  optic  nerve  is  often  diseased  in  its  whole  length,  or 
in  some  part  of  its  course,  either  within  the  skull,  in  the 
orbit,  or  at  its  ocular  end. 

The  effect  of  disease  of  the  optic  nerve  in  producing  (1) 
ophthalmoscopic  changes  in  its  visible  portion  (the  optic 
disc,  or  papilla  optica),  and  (2)  defect  of  sight,  varies 
greatly  according  to  the  seat,  nature,  and  duration  of  the 
disease.  The  appearance  of  the  disc  may  be  entirely 
altered  by  oedema  and  inflammation,  without  the  nerve- 
fibres  losing  their  conductivity,  and,  therefore,  without  loss, 
or  even  defect,  of  sight;  on  the  other  hand,  inflammatory 
or  atrophic  changes,  causing  destruction  of  the  nerve-fibres, 
may  arise  in  the  nerve  at  a  distance  from  the  eye,  and, 
whilst  producing  great  defect  of  sight,  cause  little  or  no 
immediate  change  at  the  disc.  Although  we  are  here  con- 
cerned chiefly  with  the  ophthalmoscopic  and  visual  sides  of 
the  question,  a  few  words  are  needed  as  to  the  morbid 
changes  in  the  nerve. 

The  pathological  changes  to  which  the  optic  nerve  is 
liable  include  those  which  affect  other  nerve-tissues.  In- 
flammation varying  in  seat,  cause,  and  rapidity,  and  result- 
ing in  recovery  or  atrophy,  may  originate  in  the  nerve 
itself,  may  pass  down  it  from  the  brain  (descending  neu- 
ritis), or  may  extend  into  it  from  parts  around;  atrophy 
may  occur  from  pressure  by  tumors,  or  distention  of  neigh- 
boring cavities,  e.  g.,  the  third  ventricle,  or  from  laceration 
of  the  nerve  or  its  central  vessels  in  the  orbit,  or  damage 


DISEASES     OF     THE     OPTIC     NERVE.  249 

from  fracture  of  the  optic  canal ;  and  the  optic  nerve  is 
very  subject  to  the  change  known  as  "  gray  degeneration" 
or  "  sclerosis." 

Lastly,  the  optic  nerve  being  surrounded  by  a  lymphatic 
space,"  subvaginal  space,"  which  is  continuous  through  the 
optic  foramen  with  the  meningeal  spaces  in  the  skull,  and  is 
bounded  by  a  tough,  fibrous  "outer  sheath,  "is  liable  to  be 
affected  by  morbid  processes  going  on  in  that  space.  This 
subvaginal  or  inter-sheath  space,  bounded  externally  by 
the  outer  sheath  of  the  optic  nerve,  is  lined  internally  by 
the  inner  sheath  which  is  closely  adherent  to  the  nerve 
itself,  Fig.  37.  Fluid  retained  or  secreted  in  the  subvagi- 
nal space  is  often  found  there  post-mortem,  in  cases  of  the 
optic  neuritis  about  to  be  described  as  so  commonly  asso- 
ciated with  intracranial  disease,  and  has  been  held  to  ex- 
plain the  occurrence  of  this  neuritis.  Recent  microscopical 
researches,  however,  have  shown  that  inflammatory  changes 
can  usually  be  traced  along  the  whole  course  of  the  optic 
nerves  from  their  intracranial  part  to  the  eye.  The  occur- 
rence of  optic  papillitis^  in  intracranial  disease  is  probably, 
therefore,  explained  by  an  extension  of  inflammation  from 
the  brain  or  its  membranes  either  along  the  interstitial  con- 
nective tissue  of  the  nerve  or  down  the  inner  nerve-sheath, 
or  perhaps,  in  some  cases,  along  the  intrinsic  bloodvessels  of 
the  optic  nerve.  This  explanation  by  "descending  neu- 
ritis" has  always  been  accepted  for  the  papillitis  caused  by 
meningitis  ;  bat  other  hypotheses  which  have  been,  or  seem 
likely  to  be,  given  up,  have  until  lately  been  held  by  most 
authorities  to  be  more  applicable  to  the  papillitis  caused 
by  cerebral  tumor,  because  in  this  form  the  signs  of  inflam- 
mation, as  distinguished  from  oedema  and  degeneration,  in 

'  "  Papillitis"  has  been  proposed  by  Leber  instead  of  "  neuritis"  to 
designate  the  ophthalmoscopic  appearances  of  the  inflamed  or  swollen 
disc,  without  reference  to  theories  of  causation,  or  to  the  state  of  the 
nerve-trunk, 

11* 


250  DISEASES     OF     THE     OPTIC     NERVE. 

the  nerve  above  the  disc  and  in  the  menibranesat  the  base 
of  the  brain,  are  so  slight  as  to  have  eluded  discovery  until 
sought  carefully  by  modern  microscopical  methods.  The 
part  taken  by  the  fluid  which,  as  stated  above,  is  often 
present  in  the  subvaginal  space  of  the  nerve  and  in  greatest 
quantity  close  to  the  eye,  is  not  yet  known.  It  may  act  in 
either  or  both  of  two  ways  :  mechanically,  by  compressing 
the  nerve  and  hindering  return  of  blood  from  the  retina, 
and  thus  complicating  an  already  existing  neuritis ;  or 
vitally,  by  carrying  inflammatory  germs  from  the  cranial 
cavity  to  the  optic  nerve.  It  is  not  yet  fully  known  how 
cerebral  tumors  set  up  descending  optic  neuritis  when  the 
absence  of  fluid  in  the  sheath  precludes  any  appeal  to  its 
influence  ;  but  many  facts  point  to  the  probability  that 
they  do  so  by  lighting  up  irritation  with  increase  of  cell- 
growth  in  the  surrounding  brain  substance,  and  local 
meningitis.  Xor  is  it  fully  understood  why  the  other 
cranial  nerves  are  so  seldom  damaged,  at  least  perma- 
nently.^ 

As  already  stated  in  previous  chapters,  inflammation 
may  extend  into  the  disc  from  the  retina  or  choroid  near 
to  it,  and  may  occur  in  consequence  of  the  sudden  arrest 
of  the  blood-current  caused  by  embolism  and  thrombosis 
of  the  central  retinal  vessels,  in  their  course  through  the 
nerve. 

The  ophthalmoscopic  signs  of  papillitis  are  caused  by 
varying  degrees  of  oedema,  congestion,  and  inflammation 

'  For  a  full  and  masterly  statement  of  this  diflBcult  subject,  enriched 
with  many  new  facts,  the  reader  is  referred  to  Dr.  Gowers's  Manual 
and  Atlas  of  Medical  Ophthalmoscopy.  In  recent  careful  papers  Drs. 
Edmunds  and  Lawford  maintain  that  meningitis  is  probably  always  the 
starting-point  of  optic  neuritis,  even  in  cases  of  cerebral  tumor,  and  that 
the  inflammation  usually  travels  down  the  inner  sheath  of  the  optic 
nerve,  Trans.  Ophth.  Soc,  1883-1886.  See  also  the  papers  by  Drs. 
Stephen  Mackenzie,  Brailey,  and  others,  in  the  first  volume  of  the  same 
Trans.,  1881,  and  in  the  Trans.  Internat.  Med.  Congress,  1881. 


DISEASES     OF     THE     OPTIC     NERVE.  251 

of  the  disc.  It  is  no  longer  useful  to  maintain  the  old 
ophthalmoscopic  distinction  between  "swollen  disc,"  or 
"  choked  disc,"  and  "optic  neuritis  "  The  latter  term  was 
formerly  reserved  for  cases  showing-  little  oedema  but  much 
opacity,  changes  which  were  supposed  especially  to  indicate 
inflammation  passing  down  the  nerve  from  the  brain  ;  but 
if  oedema  and  venous  engorgement  predominated,  "  choked 
disc,"  the  changes  were  attributed  to  compression  of  the 
optic  nerve  by  fluid  in  its  sheath-space,  or  with  less  reason 
to  pressure  on  the  ophthalmic  vein  at  the  cavernous  sinus. 
The  changes  are  often  mixed,  or  vary  at  different  stages  of 
thesamecase.  The  terms  "neuritis"  and  "papillitis"  will 
be  here  used  to  the  exclusion  of  "choked  disc." 

The  most  important  early  changes  in  optic  papillitis  are 
blurring  of  the  border  of  the  disc  by  a  grayish  opalescent 

Frr..  85. 


Ophthalmoscopic  appearance  of  severe  recent  papillitis.  Several 
elono:ated  patches  of  blood  near  border  of  disc.  (After  Hughlings 
Jackson.)     Compare  with  Fig.  86. 

haze,  distention  of  the  large  retinal  veins,  and  swelling  of 
the  disc  above  the  surrounding  retina.     Swelling  is  shown 


252 


DISEASES     OF     THE     0  1' TIC     NEKVE. 


by  the  abrupt  bending  of  the  vessels,  with  deepening  of 
their  color  and  loss  of  their  light  streak — they  are,  in  fact, 
seen  foreshortened;  also  by  noticing  that  slight  lateral  move- 
ments of  the  observer's  head,  or  lens,  cause  an  apparent 
movement  of  the  vessels  over  the  choroid  behind,  because 
the  two  objects  are  on  different  levels  ("parallactic  test,'- 
p.  235).  The  patient  may  die,  or  the  disease  may,  after  a 
longer  or  shorter  time,  recede  at  this  stage.  But  further 
changes  generally  occur,  the  haziness  becomes  decided 
opacity,  which  more  or  less  obscures  the  central  vessels, 
and  covers  and  extends  beyond  the  border  of  the  papilla, 
Fig.  85,  so  that  the  disc  appears  enlarged  ;  its  color  becomes 
a  mixture  of  yellow  and  pink  with  gray  or  w^hite,  and  it 
looks  striated  or  fibrous,  appearances  due  to  a  whitish 
opacity  of  the  nerve-fibres  mingled  with  numerous  small 
bloodvessels  and  hemorrhages.     The  veins  become  larger 


Fig. 


Sectiou  of  the  swollen  disc  in  papillitis,  showing  that  the  swelling  is 
limited  to  the  layer  of  nerve-fibres  (longitudinal  shading) ;  other  retinal 
layers  not  altered  in  thickness.    (Compare  with  Fig.  37.)     X  about  15. 


and  more  tortuous,  even  kinked  or  knuckled  ;  the  arteries 
are  either  normal  or  somewhat  contracted;  there  may  be 
blood-patches.     The  swelling  of  the  disc  may  be  very  great. 


DISEASES     OF     THE     OPTIC     NERVE. 


253 


and  is  appreciated  either  by  the  above-mentioned  foreshort- 
ening of  the  vessels,  by  the  parallactic  test,  or  by  ophthal- 
moscopic measurement 

Such  changes  may  disappear,  leaving  scarcely  a  trace; 
or  a  certain  degree  of  atrophic  paleness  of  the  disc,  with 
some  narrowing  of  the  retinal  vessels  and  thickening  of 
their  sheaths,  or  other  slight  changes,  may  remain.  But 
in  many  cases  the  disc  gradually,  in  the  course  of  wrecks  or 
months,  passes  into  a  state  of  "  post-papillitic"  or  "con- 
secutive" atrophy  ;  the  opacity  first  becomes  whiter  and 
smoother-looking,  "woolly  disc;"  then  it  slowly  clears  off, 
generally  first  at  the  side  next  the  yellow  spot,  and  the 
retinal  vessels  simultaneously  shrink  to  a  smaller  size, 
though  they  often  remain  tortuous  for  a  long  time,  Fig.  87. 

Fig.  87. 


Atrophy  of  disc  after  papillitis.  Upper  and  lower  margins  still  hazy  ; 
veins  still  tortuous;  arteries  nearly  normal  ;  disturbance  of  choroidal 
pigment  at  inner  and  outer  border.  Sight  in  this  case  remained  fairly 
good.     The  disc  is  not  represented  white  enough. 

As  the  mist  lifts,  the  sharp  edge,  and  finally  the  whole  sur- 
face of  the  disc,  now  of  a  staring  white  color,  again  comes 
into  view.  A  slight  haziness  often  remains,  and  the 
boundary  of  the  disc  is  often  notched  and  irregular ;  but 
upon  these  signs  too  much  reliance  must  not  be  placed. 


254  DISEASES     OF     THE     OPTIC     NERVE. 

Sight  is  seldom  much  affected^  until  marked  papillitis 
has  existed  some  little  time.  If  the  morbid  process  quickly 
cease,  often  no  failure  occurs ;  or  sight  may  fail,  may  even 
sink  almost  to  blindness,  for  a  short  time,  and  recovery  take 
place,  if  the  changes  cease  before  compression  of  the  nerve- 
fibres  has  given  rise  to  atrophy.  Early  blindness  in 
double  papillitis  may  be  due  to  pressure  on  the  chiasma  or 
tracts,  rather  than  to  the  changes  we  see  in  the  eyes. 
Gradual  failure  late  in  the  case,  when  retrogressive  changes 
are  already  visible  at  the  disc,  is  a  bad  sign.  The  sight 
seldom  changes,  either  for  better  or  worse,  after  the  signs 
of  active  papillitis  have  quite  passed  off,  and  though  the 
relations  between  sight  and  final  ophthalmoscopic  appear- 
ances vary,  it  is  usually  true  (1)  that  great  shrinking  of 
the  central  retinal  vessels  indicates  a  high  grade  of  atrophy 
and  great  defect  of  sight,  and  is  generall}"  accompanied  by 
extreme  pallor,  with  some  residual  haziness,  of  the  disc, 
advanced  post-papillitic  atrophy;  (2)  that  considerable 
pallor  and  other  slight  changes,  such  as  white  lines  bound- 
ing the  vessels,  or  streaks  caused  by  increase  of  the  connec- 
tive tissue  of  the  disc,  are  compatible  with  fairly  good  sight, 
if  the  central  vessels  be  not  much  shrunken. 

Advanced  atrophy,  undoubtedly  following  papillitis,  does 
not,  however,  always  show  signs  of  the  past  violent  inflam- 
mation; the  appearances  may,  indeed,  be  indistinguishable 
from  those  caused  by  primary  atrophy. 

Papillitis  is  double  in  the  great  majority  of  cases.  If 
single,  it  generally  indicates  disease  in  the  orbit.  It  is  true 
that  single  papillitis  from  intracranial  disease  is  occasion- 
ally met  with,  and  that  in  many  double  cases  inequalities 

1  Dr.  Hughlin;2:s  Jackson  was  the  first  to  notice  and  insist  upon  the 
frequency'  of  papillitis  without  failure  of  sight.  The  discovery  was  of 
immense  value,  for  double  papillitis,  without  other  changes  in  the  eye, 
is  one  of  the  most  important  objective  signs  we  possess  of  the  existence 
of  tumor  or  inflammation  within  the  skull. 


DISEASES     OF     THE     OPTIC     NERVE.  255 

are  often  seen  between  the  two  eyes  as  to  time  of  onset, 
degree,  and  final  result. 

The  changes  are  not  always  limited  strictly  to  the  disc 
and  its  border,  pure  papillitis,  for  in  some  cases  a  wide  zone 
of  surrounding  retina  is  hazy  and  swollen,  exhibiting  hem- 
orrhages and  white  plaques,  or  lustrous  white  diOi^,  papillo- 
retinitis. It  is  not  always  easy  to  say,  in  such  a  case, 
whether  the  changes  are  due  to  renal  disease,  with  great 
swelling  of  the  disc,  or  to  some  intracranial  malady.  In 
renal  cases  there  is  albuminuria,  the  patient  is  seldom  a 
young  child,  and  the  cases  with  more  severe  neuro-retinitis, 
where  the  differential  diagnosis  is  most  important,  occur  in 
an  advanced  stage  of  the  kidney  disease  ;^  in  the  cases  of 
neuro-retinitis  most  closely  resembling  renal  cases,  but 
caused  by  cerebral  disease,  there  is  no  albumin,  and  the 
white  deposits  are  seldom  arranged  quite  as  in  renal  retinitis, 
Fig,  *79,  whilst  the  papillitis  is  greater  than  is  usual  in  renal 
cases. 

Etiology  (compare  Chap.  XXIII.).  Papillitis  occurs 
chiefly  in  cases  of  irritative  intracranial  disease — viz.,  in 
meningitis,  both  acute  and  chronic,  and  in  intracranial 
new-growths  of  all  kinds,  whether  inflammatory  (syphilitic 
gummata),  tubercular,  or  neoplastic.  It  is  very  rare  in 
cases  where  there  is  neither  inflammation  nor  tissue  growth, 
as  in  cerebral  hemorrhage  and  intracranial  aneurism. 
Further,  it  must  be  stated  that  no  constant  relationship  has 
been  proved  between  papillitis  and  the  seat,  extent,  or 
duration  of  the  intracranial  disease.  Papillitis  has  occa- 
sionally been  found  without  coarse  disease,  but  with  widely 
diffused  minute  changes,  in  the  brain.  Thus,  the  occurrence 
of  papillitis,  although  pointing  very  strongly  to  organic 
disease  within  the  skull,  and  especially  to  intracranial 
tumor,  is  not  of  itself  either  a  localizing  or  a  differentiating 

1  Gowers,  p.  187. 


256  DISEASES     OF     THE     OPTIC     NERVE. 

symptom.  Inflammation  about  the  sphenoidal  fissure,  and 
tumors,  nodes,  and  inflammations  in  the  orbit,  are  occasional 
causes  of  papillitis,  which  is  then  usually  one-sided,  and 
often  accompanied  by  extreme  oedema  and  venous  disten- 
tion ;  in  some  of  these  there  is  protrusion  of  the  eye  with 
affection  of  other  orbital  nerves,  and  the  exact  seat  and 
nature  of  the  disease  may  be  obscure.  Optic  neuritis  from 
intracranial  disease  very  seldom  recurs  after  subsidence.* 

Other  occasional  causes  of  double  papillitis,  with  or 
without  retinitis,  are  lead-poisoning,  the  various  exanthe- 
mata (including  recent  syphilis),  sudden  suppression  of 
menses,  simple  chronic  anaemia,  rapid  copious  loss  of  blood, 
especially  from  the  stomach,  and,  perhaps,  exposure  to  cold. 
In  a  few  cases,  well-marked  double  papillitis  occurs  without 
other  symptoms,  and  without  assignable  cause. 

Certain  cases  of  failure  of  sight,  usually  single,  with 
slight  neuritic  changes  at  the  disc,  followed  by  recovery  or 
by  atrophy,  must  be  referred  to  a  local,  primary,  optic 
neuritis  some  distance  behind  the  eye,  retro-ocular  neuritis. 
The  changes  are,  clinically,  very  different  from  those  above 
described. 

Syphilitic  disease  within  the  skull  is  a  common  cause 
of  papillitis,  but  the  eye-changes  alone  furnish  no  clue  to 
the  cause,  nor  to  its  mode  of  action,  which  may  be  (1)  by 
giving  rise  to  intracranial  gummata,  not  in  connection  with 
the  optic  nerves,  but  acting  as  any  other  tumor  acts  (see 
above) ;  (2)  by  direct  implication  of  the  chiasma  or  optic 
tracts  in  gummatous  inflammation  ;  (3)  in  rare  cases  neu- 
ritis, ending  in  atrophy  and  blindness,  occurs  in  secondary 
syphilis,  with  head  symptoms  pointing  to  meningitis;  (4) 
there  are  few  cases  of  double  papillitis  in  late  secondary 
syphilis,  without  either  head  symptoms  or  signs  of  ocular 

1  A  well-marked  case  has,  however,  beeu  recorded  by  Dr.  James 
Anderson  in  the  Ophthalmic  Review  for  May,  1886. 


ATROPHY     OF     THE     OPTIC     DISC. 


257 


disease  other  than  in  the  discs  ;  these  may  properly  be 
called  "syphilitic  optic  neuritis." 

The  condition  of  the  pupil  in  neuritic  affections  depends 
partly  on  the  degree  and  partly  on  the  rapidity  of  failure 
of  vision.  As  a  rule,  in  amaurosis  from  atrophy  of  the 
discs  after  papillitis,  the  pupils  are,  for  a  time,  rather 
widely  dilated  and  motionless;  after  a  \Yhile  they  often 
become  smaller,  and,  unless  the  blindness  be  complete, 
they  regain  a  certain  amount  of  mobility  to  light. 

Atrophy  of  the  Optic  Disc. 

By  this  is  meant  atrophy  of  the  nerve  fibres  of  the  disc 
and  of  the  capillary  vessels  which  feed  it.  The  disc  is  too 
white ;  milk-white,  bluish,  grayish,  or  yellowish,  in  different 
cases.     Its  color  may  be  quite  uniform,  or  some  one  part 


Fig.  88. 


Fig.  89. 


Simple  atrophy  of  disc.  Stip- 
pling of  lamina  cribroea  exposed. 
(Wecker.) 


Atrophy  of  disc  from  spinal  dis- 
ease. Lamina  cribrosa  concealed. 
Vessels  normal.     (Wecker.) 


may  be  whiter  than  another  ;  the  stippling  of  the  lamina 
crihrosa  may  be  more  visible  than  in  health,  or,  on  the 
other  hand,  entirely  absent,  as  if  covered,  or  filled  up  by 
white  paint,  Figs.  88  and  89.  The  central  retinal  vessels 
may  be  shrunken  or  of  full  size,  and  their  course  natural 


258  DISEASES     OF     THE     OPTIC     NERVE. 

or  too  tortuous ;  both  these  points  bear  upon  the  diagnosis 
of  cause  and  the  prognosis.  The  choroidal  boundary  may 
be  too  sharply  defined,  or,  as  in  Fig.  87,  too  hazy;  it  may 
be  even  and  circular,  or  irregular  and  notched.  The  scle- 
rotic ring  is  often  seen  with  unnatural  clearness,  exposed 
by  wasting  of  the  overlying  nerve  fibres.  Mere  pallor  of 
the  disc,  such  as  we  see  in  extreme  general  anaemia,  must 
not  be  mistaken  for  atrophy:  the  change  is  then  one  of 
color  onl}^,  without  unnatural  distinctness,  loss  of  trans- 
parency, or  disturbance  of  outline. 

Varieties — (1.)  The  nerve  fibres  undergo  atrophy  during 
the  absorption  and  shrinking  of  the  new  connective  tissue 
formed  in  severe  neuritis  (post-papillitic  atrophy,  p.  253 ; 
embolism,  p.  242) 

(2.)  When  the  disc  participates  secondarily  in  inflamma- 
tion of  the  retina  or  choroid  it  also  participates  in  the  suc- 
ceeding atrophy. 

(3.)  Atrophy  of  any  part  of  the  optic  nerve  or  chiasma 
from  pressure — as  by  a  tumor  or  by  distention  of  the  third 
ventricle  in  hydrocephalus — from  injury  or  local  inflam- 
mation, leads  to  secondar}^  atrophy,  which  sooner  or  later 
reaches  the  disc.  Such  cases  often  show  the  condition  of 
pure  atrophy,  without  adventitious  opacity  or  disturbance 
of  outline,  and  often  without  change  in  the  retinal  vessels. 
They  are  not  very  common. 

(4.)  The  optic  nerves  are  liable  to  chronic  sclerotic 
changes,  with  thickening  of  the  connective-tissue  framework 
and  atrophy  of  the  nerve-fibres,  without  the  occurrence  of 
papillitis.  The  change  in  these  cases  appears  ofte  n  to  begin 
at  the  disc,  but  the  exact  order  of  events  in  this  large  and 
important  group  is  not  fully  known.  Groups  3  and  4 
furnish  the  cases  which  are  known  clinically  as  "  primary" 
or  "progressive"  atrophy  of  the  optic  disc. 

Clinical  aspects  of  atrophy  of  the  discs — As  in  optic 
neuritis,  so  in  atrophy  and  pallor  of  the  disc,  there   is  no 


ATROPHY     OF     THE     OPTIC     DISC, 


259 


invariable  relation  between  the  appearance,  especially  the 
color,  of  the  disc  and  the  patient's  sight.  A  considerable 
degree  of  pallor,  which  it  may  be  impossible  to  distinguish 
from  true  atrophy,  is  sometimes  seen  with  excellent  central 


Fig.  90. 


Irregular  contraction  of  fields  of  vision  in  a  case  ot  progressive  atrophy 
of  optic  nerves.  The  loss  is  symmetrical,  but  more  advanced  in  the 
L.,  where  it  has  extended  over  the  fixation  point ;  in  the  R.  it  has  just 
reached  the  fixation  point  at  one  place.  The  black  represents  the  parts 
lost. 

Fig.  91. 


Irregular  contraction,  with  central  loss  of  L.  visual  field,  from  pro- 
gressive atrophy  of  optic  nerve  in  locomotor  ataxy.  The  black  repre- 
sents the  blind  parts  ;  the  shading  shows  partial  loss  of  vision. 

vision,  though  usually  accompanied  by  some  defect  of  the 
visual  field.  Again,  the  discs  often  look  alike,  although 
the  sight  is  much  better  in  one  than  the  other. 


2G0  DISEASES     OF     THE     OPTIC     NERVE. 

Patients  with  atrophy  of  the  disc  come  to  us  because 
they  cannot  see  well  or  are  quite  blind.  There  are  usually 
no  other  local  symptoms  except  such  as  may  be  furnished 
by  the  pupils.  In  post-papillitic  atrophy  the  pupils  are 
generally  too  large  and  sluggish  or  motionless  to  light ;  in 
most  cases  of  primary  progressive  atrophy  they  are  of  or- 
dinary size,  or  smaller  than  usual,  and  act  very  imper- 
fectly. (Chap.  XXIII.)  When  only  one  eye  is  affected, 
the  other  being  quite  healthy,  the  pupil  of  the  amaurotic 
eye  has  no  direct  action  to  light,  and  is  often  a  little  larger 
than  its  fellow. 

The  visual  field,  in  cases  of  atrophy,  is  generally  con- 
tracted, or  shows  irregular  invasions  or  sector-like  defects, 
Figs.  90  and  91.  Color-blindness  is  a  marked  symptom  in 
nearly  all  cases,  but  is  not  always  proportionate  to  the  loss 
of  visual  acuteness,  being  in  some  much  greater  and  in 
others  much  less  than  the  state  of  central  vision  would 
lead  us  to  expect.  Green  is  the  color  lost  soonest  in  nearly 
all  cases,  and  red  next. 

A.  Cases  in  which  both  discs  are  atrophied  may  be  con- 
veniently classified  as  follows  in  regard  to  diagnosis  and 
prognosis : 

(1.)  If  the  changes  point  decidedly  to  recently  past 
papillitis  there  is  some  prospect  of  improvement ;  but  on 
the  other  hand,  sight  may  for  a  time  get  worse.  The  case 
must,  of  course,  be  investigated  most  carefully  as  to  the 
cause  of  the  neuritis.  If  sight  have  been  stationary  for 
some  months  further  change  is  unlikely. 

(2.)  If  the  retinal  arteries  are  much  shrunken,  whether 
neuritis  have  occurred  or  not,  the  prognosis  is  bad. 

(3.)  If  we  cannot  decide  after  careful  examination 
whether  or  no  papillitis  have  preceded,  inquiry  should  be 
made  as  to  former  symptoms  of  intracranial  disease,  since 
consecutive  cannot  always  be  distinguished  from  primary 
atrophy.     But  in  a  large  number  of  those  cases  which  pre- 


ATROPHY     OF     THE     OPTIC     DISC.  261 

sent  no  ophthalmoscopic  evidence  of  previous  papillitis, 
the  history  will  be  quite  negative  as  to  cerebral  symptoms ; 
— and  these  will,  for  the  most  part,  fall  into  the  two  follow- 
ing groups. 

(4.)  There  are  symptoms  of  chronic  disease  of  the  spinal 
cord,  usually  of  locomotor  ataxy ;  or  much  more  rarely 
symptoms  of  general  paralysis  of  the  insane. 

(5.)  No  cause  can  be  assigned  for  the  atrophy.  Theseare 
less  common  than  has  been  supposed. 

The  sclerosis  leading  to  atrophy  of  the  discs  in  locomotor 
ataxy  (4)  usually  comes  on  early  in  that  disease,  often  be- 
fore well-marked  spinal  symptoms  have  appeared.  The 
optic  atrophy  always  becomes  symmetrical,  though  it  gen- 
erally begins  some  months  sooner  in  one  eye  than  in  the 
other;  it  always  progresses,  though  sometimes  not  for  years, 
to  complete,  or  all  but  complete,  blindness.  The  discs  are 
usually  characterized  by  a  uniformly  opaque,  gray-white 
color,  the  lamina  cribrosa  being  often  concealed,  although 
neither  the  central  vessels  nor  the  disc  margins  are  ob- 
scured in  the  least,  Fig.  89.  The  central  vessels  are  often 
not  materially  lessened  in  size,  even  when  the  patient  is 
quite  blind. 

Cases  of  progressive  atrophy  are  seen  which  resemble 
the  above,  but  where  no  signs  of  spinal-cord  disease  are 
present,  even  though  the  patient  have  been  long  blind  (5). 
It  is  known  that  in  some  of  these  patients  ataxic  symptoms 
come  on  sooner  or  later,  and  it  is  highly  probable  that, 
could  the  cases  be  followed  up  for  a  sufficient  number  of 
years,  this  termination  would  be  found  to  be  common.^ 

^  I  have  found  decided  spinal  symptoms  in  .58  of  a  series  of  76  con- 
secutive cases  of  progressive  atroph}',  and  of  the  remaining  18,  several 
showed  one  or  more  symptoms  which  were  probably  of  spinal  origin. 
Peltesohn  finds  about  40  per  cent,  of  all  cases  of  non-neuritic  pro- 
gressive optic  atrophy,  in  Hirschberg's  clinic,  to  be  associated  with 
spinal  or  cerebro-spinal  disease.     Knapp's  Arch.,  xvi.  142. 


262  DISEASES    OF    THE    OTTIO     NERVE. 

Indeed,  pre-ataxic  optic  atrophy  is  now  a  recognized 
method  of  onset  of  the  disease.  Cases  of  Classes  4  and  5 
are  far  commoner  in  men  than  women.  In  a  few  the 
atrophy  is  caused  by  the  pressure  of  a  tumor  which  com- 
presses the  chiasma,  without  setting  up  papillitis. 

In  making  the  prognosis  of  cases  of  progressive,  uncom- 
plicated amblyopia  or  amaurosis,  with  more  or  less  atrophy 
of  discs,  special  attention  is  to  be  paid  to  whether  or 
not  the  failure  was  synchronous,  and  whether  it  is  now 
equal  in  the  two  eyes.  The  state  of  the  field  of  vision  in 
cases  seen  early  is  also  of  much  importance  ;  peripheral 
contraction,  as  distinguished  from  central  defect,  is  a  bad 
sign,  for  progressive  atrophy  seldom  begins  with  defect  in 
the  centre  of  the  field.  In  cases  of  gradual,  uncomplicated 
failure  of  sight,  where  the  svmptoms  have,  from  the  begin- 
ning, been  equally  symmetrical,  the  atrophic  changes  are 
usually  but  slight  in  comparison  with  the  defect  of  sight. 

B.  Single  amaurosis  with  atrophy  ofth  e  disc,  in  a  majority 
of  the  cases,  indicates  former  embolism  of  the  central  artery, 
some  local  affection  of  the  trunk  of  the  optic  nerve,  "  retro- 
ocular  neuritis,"  or  pressure  on  the  nerve  by  tumor  just  in 
front  of  the  chiasma.  But  here  it  must  be  remembered 
that  in  cases  of  progressive  atrophy,  accompanying  or  pre- 
ceding spinal  disease,  a  very  long  interval  occasionally  sepa- 
rates the  onset  of  the  disease  of  the  two  eyes,^  and  we  may 
see  the  first  eye  before  the  commencement  of  the  disease  in 
the  second. 

Blindness  of  one  eye  following  immediately  after  a  fall 
or  blow  on  the  head,  and  leading  in  a  few  weeks  to  atrophy, 
indicates  damage  to  the  nerve  from  fracture  of  the  optic 
canal.  The  blow  has  generally  been  on  the  front  of  the 
head,  and  on  the  same  side  as  the  aflected  eye.     A  similar 

1  This  interval  may  be  three  or  four  years,  and  an  interval  of  from 
one  to  two  years  is  not  very  rare. 


ATROPHY    OF    THE     OPTIC    DISC.  263 

condition  follows  wound  or  rupture  of  the  nerve  in  the 
orbit,  by  a  thrust,  stab,  or  gunshot  injury.  Laceration  of 
the  central  retinal  vessels  alone,  behind  the  point  at  which 
they  enter  the  nerve,  is  said  to  cause  appearances  like 
those  due  to  embolism  and  thrombosis.  In  cases  of  injury 
to  the  optic  nerve  improvement  is  rare. 


CHAPTER  XV . 

AMBLYOPIA  AND  FUNCTIONAL  DISORDERS  OF  SIGHT. 

The  term  amblyopia  means  dulness  of  sight,  but  its  use 
is  generally  restricted  to  cases  of  defective  acuteness  of 
sight,  short  of  blindness,  in  which  there  is  little  or  no  oph- 
thalmoscopic change.  Amaurosis  indicates  a  more  advanced 
affection,  complete  blindness  without  visible  changes. 
These  terms,  then,  refer  to  the  patient's  symptoms,  whilst 
papillitis  and  atrophy  imply  changes. seen  by  the  observer. 
Amblyopia  may  depend  upon  disease  in  the  retina,  in  any 
part  of  the  optic  nerve  or  tract,  or  in  the  optic  centres  ;  and 
it  may  be  temporary  or  permanent.  It  is  always  most 
important  to  distinguish  single  from  symmetrical  cases. 

Two  common  and  important  forms  of  unsymmetrical 
amblyopia  ma}^  be  considered  first. 

(1.)  Amblyopia  from  suppression  of  image  (^'congenital 
amblyopia^^). — It  is  well  known  that  many  children  with 
convergent  squint  see  badly  with  the  squinting  eye;  that 
this  defect  varies  in  degree,  and  may  be  so  great  that  fingers 
can  hardly  be  counted ;  that,  at  any  rate  in  the  higher 
grades,  the  defect  is  chiefly,  or  only,  present  in  that  part  of 
the  visual  field  which  is  common  to  both  eyes,  Fig.  23,  and 
is  irremediable,  whilst  in  the  lower  degrees  the  defect  may 
be  more  or  less  removed  by  separate  practice  of  the  defec- 
tive eye.^  It  has  been  assumed  by  one  school  that  this  am- 
blyopia is  due  to  a  congenital  defect,  presumably  of  the  vis- 
ual centre,  whichdeterminesthe  incidence  of  the  squint,  just 

^  Of  such  improvement  I  have  myself  had  very  little  experience. 


AMBLYOPIA.  265 

as  defect  due  to  an  ulcer  of  the  cornea  may  do.  Another  view 
supposes  that  the  child,  born  with  two  good  eyes,  but  being 
obliged  to  squint  owing  to  hypermetropia,  learns  to  sup- 
press the  consciousness  of  the  image  in  the  squinting  eye 
in  order  to  avoid  the  inconvenience  of  double  vision,  and 
that  this  habit,  if  begun  very  early  in  life,  causes  perma- 
nent amblyopia  of  the  eye,  or  rather  loss  of  perception  in 
the  corresponding  centre.  For  the  former  view  it  is  urged, 
that  no  one  has  ever  watched  the  onset  of  this  amblyopia, 
since  it  is  always  present  at  the  youngest  age  when  tests  can 
be  applied ;  that  we  meet  with  cases  of  unexplained  defect 
of  one  eye  without  squint ;  and  that  this  supposed  power  of 
suppression  cannot  be  learnt  in  later  life,  as  is  shown  by 
the  permanence  of  diplopia  in  all  cases  of  paralytic  squint 
acquired  after  childhood.  In  favor  of  the  suppression 
theory  we  may  argue,  that  whilst  such  defect  might  be 
acquired  early,  it  could  not  be  expected  to  come  on  late, 
after  the  visual  centre  in  question  had  been  educated  ;  pre- 
cisely as  want  of  training  of  the  ocular  muscles  in  early 
infancy,  from  defective  sight  due  to  disease,  leads  to  incur- 
able nystagmus  (Chap.  XXI.)  much  more  frequently  than 
do  similar  defects  of  sight  acquired  after  the  muscles  have 
been  got  into  harmonious  use ;  that  in  many  of  the  cases 
of  defect  without  squint  a  history  of  previous  squint  can 
be  obtained-/  and  that  if  the  defect  were  congenital  it 
would  involve  the  whole  field  equally,  not  onlv  that  part 
which  is  common  to  the  two  eyes.  In  alternating  concomi- 
tant squint,  whether  convergent  or  divergent,  there  is  no 
diplopia,  although  the  vision  of  each  eye  is  as  a  rule  equally 
good ;  the  patient  has  the  power  of  instantaneously  sup- 
pressing the  consciousness  of  the  image  in  whichever  hap- 
pens to  be  the  squinting  eye,  a  fact  in  favor,  so  far  as  it 

1  I  believe  that  the  spontaneous  disappearance  of  hypermetropic 
Bquint,  Avhich  is  not  uncommon,  has  received  too  little  attention. 

12 


266  AMBLYOPIA. 

goes,  of  the  suppression  theory. .  On  the  other  hand,  it  is 
true  that  in  cases  of  anisometropia  great  variations  are 
encountered  in  the  degree  of  perfection  to  which  the  more 
ametropic  eye  can  be  raised  by  glasses,  a  fact  perhaps  in 
favor  of  the  congenital  amblyopia  theory. 

(2.)  Amblyopia  from  defective  retinal  images.— In 
cases  of  high  hypermetropia  or  astigmatism,  when  clear 
images  have  never  been  formed,  the  correction  of  the 
optical  defect  by  glasses  at  the  earliest  practical  age  often 
fails,  at  any  rate  for  a  time,  to  give  full  acuteness  of  sight. 
Want  of  education  in  the  appreciation  of  clear  images  is 
probably  the  chief  cause,  though  defective  development  of 
the  retina  may  also  come  into  play.  We  may  explain  in 
the  same  way  the  common  cases  in  which,  with  anisome- 
tropia (Chap.  XX.),  the  sight  of  the  more  ametropic  eye, 
even  when  corrected  by  the  proper  glasses,  remains  defec- 
tive, although  no  squint  have  ever  existed  ;  and  in  some 
degree  also  the  defect  often  observed  after  perfectly  suc- 
cessful operations  for  cataract  in  children.  Amblyopia  of 
this  kind  when  discovered  late  in  life  is  seldom  altered 
by  correcting  the  optical  error,  but  in  children  the  sight 
often  improves  when  suitable  glasses  are  constantly  worn. 

Great  defect  of  one  eye,  from  the  cause  just  mentioned, 
or  gradual  painless  failure  from  disease,  often  exists  un- 
known for  years,  until  accidentally  discovered  by  closing 
the  sound  eye,  or  by  trying  the  sight  of  each  eye  separately, 
e.  g.,  in  an  examination  for  the  army  or  other  public  ser- 
vice. The  patient  in  such  cases  is  naturally  concerned  at 
what  he  thinks  is  a  recent  defect,  but  caution  is  needed  in 
accepting  his  views,  unless  he  have  previously  been  in  the 
habit  of  "  sighting  "  objects  wnth  the  eye  in  question,  as  in 
rifle-shooting.  But  sudden  failure  of  one  eye  is,  as  a  rule, 
dated  correctly. 

In  cases  of  amblyopia  not  belonging  to  the  above  cate- 
gories, a  definite  date  of  onset  will  generally   be  given. 


AMBLYOPIA.  26Y 

Two  principal  divisions  may  be  formed,  according  as  the 
amblyopia  affects  one  eye  or  both. 

(3.)  Cases  of  recent  failure  of  one  eye  with  little  or  no 
ophthalmoscopic  change  occur  rather  rarely,  and  generally 
in  young  adults;  the  onset  is  often  rapid,  with  neuralgic 
pain,  sometimes  very  severe,  in  the  same  side  of  the  head. 
There  may  be  pain  in  moving  the  eye,  or  tenderness  when 
it  is  pressed  back  into  the  orbit.  The  degree  of  amblyopia 
varies  much,  but  is  often  especially  marked  at  the  centre 
of  the  field.  The  disc  of  the  affected  eye  is  sometimes  liazy 
and  congested.  The  attack  is  often  attributed  to  exposure 
to  cold.  Most  of  the  cases  recover  under  the  use  of  blisters 
and  iodide  of  potassium,  but  in  a  certain  number  the  defect 
is  permanent,  and  the  disc  becomes  atrophied.  A  retro- 
oc?//a?' ??ew7'i7zs,  often  slight  and  transient.most  likely  occurs, 
and  the  cases  are  perhaps  analogous  to  peripheral  paralysis 
of  the  facial  nerve. 

(4.)  Much  commoner  is  a  progressive  and  equal  failure 
in  both  eyes,  often  amounting  in  a  few  weeks,  or  months, 
to  great  defect  (14  or  20  Jaeger,  or  V.  from  \  to  y'^),  with 
no  other  local  symptoms  except  perhaps  a  little  frontal 
headache,  but  often  with  nervousness,  general  want  of  tone, 
and  loss  of  sleep  and  appetite.  Ophthalmoscopic  changes, 
never  pronounced,  may  be  quite  absent:  at  an  early  period 
the  disc  is  often  decidedly  congested,  and  slightly  swollen 
and  hazy,  but  these  changes  are  all  so  ill-marked  that  com- 
petent observers  may  give  different  accounts  of  the  same 
case;  later,  the  side  of  the  disc  near  the  y.  s.,  and,  finally, 
in  bad  cases,  the  whole  papilla,  become  pale,  and  the  diag- 
nosis of  incomplete  atrophy  is  given.  The  defect  of  sight 
is  described  as  a  "mist,"  and  is  usually  most  troublesome 
in  bright  light  and  for  distant  objects,  being  less  apparent 
early  in  the  morning  and  toward  evening.  The  pupils  are 
normal,  or  at  most  rather  sluggish  to  light.  The  defect  of 
y.  is  limited  to,  or  most  intense  at,  the  central  part  of  the 


268 


AMBLYOPIA. 


field,  central  scotoma,  occupying  an  oval  patch  which  ex- 
tends from  the  fixation  point  (corresponding  to  the  y.  s.) 
outward,  toward,  and  often  as  far  as,  the  blind  spot,  cor- 
responding to  the  optic  disc.  The  affected  area  is  also 
found  to  be  color-blind  for  red  and  green  ;  but  this  loss  of 
color-perception  being  usually  incomplete,  alike  in  degree 
and  superficial  extent,  Fig.  92,  will  often  escape  detection 

Fig.  92. 


R.  right,  L.  left,  visual  field  in  a  case  of  central  amblyopia  from 
tobacco-smoking.  The  shaded  area  is  the  part  over  which  acuteness  of 
vision  and  color-perception  are  lowered  (relative  central  scotoma),  no 
part  of  the  field  being  absolutely  blind.  The  dotted  line  marked  R. 
shows  the  boundary  of  the  field  for  red  (see  Fig.  22). 

if  large  color-tests  be  used;  whilst  it  will  readily  be  found 
by  using  a  small  colored  spot  of  from  5  to  15  mm.  square. 
The  patient,  closing  one  eye,  "fixes"  the  finger  or  nose  of 
the  observer,  who  then  removes  the  colored  spot  from  the 
fixation  point  in  various  directions  toward  the  periphery  ; 
the  color,  instead  of  appearing  brightest  at  the  centre  of  the 
field,  will  be  dull  or  unrecognizable  there,  becoming  brighter 
and  easily  recognized  toward  the  periphery.  There  is  no 
contraction  of  the  field,  and  thus,  since  surrounding  objects 
are  seen  as  well  as  ever,  and  the  patient  has  no  diflBculty 
in  going  about,  his  manner  differs  from  that  of  one  with 
progressive  atrophy,  who  finds  difficulty  in  guiding  himself, 
because  his  visual  field  is  contracted. 


AMBLYOPIA.  269 

The  patiects  are,  almost  without  exception,  males,  and 
at  or  beyond  middle  life.  With  very  rare  exceptions  they 
are  smokers,  and  have  smoked  for  many  years,  and  a  large 
number  are  also  intemperate  in  alcohol.  The  exceptions 
occur  chiefly  in  a  very  few  patients  to  whom  a  similar  kind 
of  amblyopia  is  hereditary,  is  liable  to  affect  the  female  as 
well  as  the  male  members,  and  may  come  on  much  earlier 
in  life.  The  etiology  of  such  cases  is  obscure,  and  in  some 
few  of  them  there  is  no  evidence  of  heredity. 

In  the  common  cases  it  is  now  generally  agreed  that 
tobacco  has  a  large  share  in  the  causation,  and  in  the 
opinion  of  an  increasing  number  of  observers  it  is  the  sole 
excitant.  The  direct  influence  of  alcohol,  and  of  the 
various  causes  of  general  exhaustion,  such  as  anxiety, 
underfeeding,  and  general  dissipation,  is  still  to  some  ex- 
tent an  open  question  (see  Chap.  XXIII.,  Diabetes).  My 
own  opinion,  based  on  the  examination  of  a  large  number 
of  cases,  is  that  tobacco  is  the  essential  agent,  and  that  the 
disuse,  or  greatly  diminished  use,  of  tobacco  is  the  one 
essential  measure  of  treatment.  It  is  important  to  remem- 
ber that  the  disease  may  come  on  when  either  the  quantity 
or  the  strength  of  the  tobacco  is  increased,  or  when  the 
health  fails  and  a  quantity  which  was  formerly  well  borne 
becomes  excessive.  Hence,  cases  of  double  central  ambly- 
opia may,  as  a  rule,  except  in  the  rare  form  above  men- 
tioned, be  named  tobacco  amblyopia.  The  symmetry  of 
tobacco  amblyopia  is  not  always  precise,  and  it  appears, 
in  very  rare  cases,  to  be  delayed.^ 

The  prognosis  is  good  if  the  patient  come  early,  and  if 
the  failure  have  been  comparatively  quick.  In  such  cases 
really  perfect  recovery  may  occur,  and  very  great  improve- 
ment is  the  rule.  In  the  more  chronic  cases,  or  cases  where 
already  the  whole  disc  is  pale,  a  moderate  improvement,  or 

*  J.  Hutchinson,  Jr.,  Ophth.  Hosp.  Reports,  xi.,  1886. 


270  AMBLYOPIA. 

even  an  arrest  of  progress,  is  all  we  can  expect.  If  smok- 
ing be  persisted  in,  no  improvement  takes  place,  and  the 
amblyopia  increases  up  to  a  certain  point,  but  complete 
blindness  very  seldom,  if  ever,  occurs.  In  the  treatment, 
disuse  of  tobacco  is  the  one  thing  essential.  Relapse  some- 
times occurs  if  smoking  be  resumed.  Drink  should,  of 
course,  be  moderated.  It  is  usual  to  give  strychnia,  sub- 
cutaneously  or  by  mouth,  for  a  considerable  period,  but 
whether  any  medicine  acts  otherwise  than  by  improving 
the  general  tone  is  doubtful ;  subcutaneous  injections  of 
strychnia,  carefully  carried  out,  have  not  given  definite 
results  in  my  own  cases.  Others  believe  that  the  constant 
current  is  useful.  There  is  reason  to  believe  that  the  dis- 
ease depends  on  a  chronic  inflammation  of  the  central 
bundles  of  the  optic  nerve,  beginning  at,  or  at  a  short  dis- 
tance behind,  the  eye.^ 

Hemianopia,  usually  csbWedhemiopia,  denotes  loss  of  half 
the  field  of  vision.  When  uniocular,  the  defect  is  seldom 
quite  regular,  and  generally  depends  upon  detachment  of 
the  retina  or  a  very  large  retinal  hemorrhage.  It  is  usu- 
ally binocular,  and  then  indicates  disease  at  or  behind  the 
optic  chiasma.  In  the  great  majority  of  cases  the  R.  or  L. 
lateral  half  of  each  field  is  lost.  Sometimes  only  a  quarter 
of  each  field  is  lost.  The  line  of  separation  between  the 
blind  and  seeing  halves  is  usually  sharply  defined  and 
nearly  straight,  only  deviating  a  degree  or  two  at  the  fix- 
ation point  so  as  just  to  leave  central  vision  intact  over  an 
area  about  corresponding  to  the  fovea  centralis.  Fig.  93. 
In  other  cases  the  separating  line  is  undulating  and  a  com- 
paratively large  central  area  of  the  field  remains  intact. 
The  boundary  between  sight  and  blindness  in  hemianopia, 
though  usually  abrupt,  is  sometimes  gradual.  The  reten- 
tion of  central  vision  over  a  considerable  central  area  has 

1  Trans.  Ophth.  Soc,  vol.  i.  p.  124,  and  iii.  p.  160. 


HEMIANOPIA.  211 

been  explained  on  the  assumption  that  the  j.  s.  area  re- 
cei^^es  nerve-fibres  from  both  optic  tracts,  and  Bunge  and 
others  have  lately  found  microscopical  evidence  that  such 
is  really  the  case  ;  in  cases  like  Fig.  93,  the  apparent  devi- 
ation of  the  dividing  line  may  perhaps  be  explained  by  the 

Fig.  93. 

CO 

Fields  of  vision  in  a  case  of  L.  homonymous  lateral  Hemianopia. 
The  dividiug  line  comes  within  one  or  two  degrees  of  the  fixation  point 
(shown  by  the  central  dot)  in  each  eye.  The  lesion  causing  this  hem- 
ianopia is  probably  in  the  optic  tract,  or  not  higher  than  the  corpora 
genie  ulata. 

difficulty  which  the  patient  has  in  keeping  the  eye  perfectly 
fixed  when  the  test  object  comes  close  to  the  centre. 
Loss  of  the  R.  half  of  esich  field,  meaning  loss  of  function 
of  the  L.  half  of  each  retina,  points  to  disease  of  the  L. 
optic  tract'  or  its  continuations,  or  of  some  part  of  the  L. 
occipital  lobe  or  angular  gyrus.  Loss  of  the  two  nasal 
halves  is  extremely  rare.  Loss  of  the  two  temporal  halves, 
temporal  hemianopia,  points  to  disease  at  the  anterior  part 
of  the  chiasma.  Even  when  hemianopia  has  lasted  for 
years  the  optic  discs  seldom  show  any  change.  When  the 
lateral  hemianopia  coexists  with  hemiplegia,  the  loss  of 
sight  is  on  the  paralyzed  side;   "the  patient  cannot  see 

^  Because  the  L.  optic  tract  consists  chiefly  of  fibres  which  supply 
most  of  the  L.  half  of  each  retina,  those  of  them  destined  for  the  R. 
eye  crossing  over  at  the  optic  commissure. 


272  AMBI.  YOPTA. 

to  his  paralyzed  side"  (Hughliiigs  Jacksoii).  If  double 
hemiopia  occurs  the  patient  is  totally  blind  in  both  eyes. 
A  nothcr  less  common  affection  of  sight,  crossed  amblyopia, 
is  believed  to  be  due  to  a  lesion  of  a  higher  centre  in  the 
angular  gyrus  which  presides  in  some  degree  over  the 
whole  of  both  fields  of  vision,  but  chiefly  over  that  of  the 
opposite  eye.  A  unilateral  lesion  of  this  kind  produces 
amblyopia  with  great  contraction  of  the  field  of  the  oppo- 
site eye,  and  with  some  contraction  of  the  field  of  the  eye 
on  the  same  side.  The  symptoms  are  much  like  those  of 
hysterical  amblyopia  in  one  eye.  If  such  a  lesion  were 
double  it  would  presumably  produce  a  high  degree  of  am- 
blyopia, with  contraction  of  the  fields  in  both  eyes,  the 
activity  of  the  pupils  being  retained.  A  few  cases  of  hemi- 
anopia  for  colors  alone  have  been  recorded.^ 

Hysterical  amblyopia  and  amaurosis  take  various  forms, 
and  real  defect  may  be  mixed  up  with  feigning.  In  hys- 
terical hemiansesthesia  the  eye  on  the  affected  side  is  some- 
times defective  or  quite  blind.  In  other  cases  of  hysteria 
both  eyes  are  defective,  but  one  worse  than  the  other  ; 
there  is  concentric  contraction  of  the  visual  fields,  some- 
times with  and  sometimes  without  color-blindness,  a  vary- 
ing degree  of  defective  visual  acuteness,  and  sight  is  often 
disproportionately  bad  by  feeble  light  (hence  the  term 
"  anaesthesia  of  the  retina"  is  sometimes  used).  There 
may,  however,  be  in  addition  irritative  symptoms — water- 
ing, photophobia,  and  spasm  of  accommodation — and  then 
the  term  "  hyperaesthesia  retinae,"  or  "  oculi,"  seems  more 
appropriate.  Amblyopia  with  the  above  characters  has 
been  known  to  follow  a  blow  upon  the  eye  affected  which 
was  so  slight  as  not  to  cause  the  least  ophthalmoscopic 
change  ;  again,  when  one  eye  has  been  suddenly  lost  by 
wound  or  embolism  a  condition  indistinguishable  from  hys- 

^  See  an  exhaustive  paper  by  Mackay,  Brit.  Med.  Journ.,  Nov. 10, 1888. 


HYSTERICAL     AMBLYOPIA.  273 

terical  blindness  may  rapidly  come  on  in  the  other.  It  is 
important  to  note  that  in  hysterical  amblyopia,  even  of 
high  degree  and  long  standing,  the  reflex  action  of  the 
pupil,  direct  as  well  as  indirect,  is  fully  preserved,  and  the 
ophthalmoscopic  appearances  quite  normal.  The  prognosis 
is  nearly  always  good,  though  recovery  is  sometimes  slow, 
and  relapses  may  occur.  In  some  of  the  worst  cases  I 
have  seen  there  has  been  considerable  ametropia. 

True  hysterical  amblyopia  seems  allied,  from  the  oph- 
thalmic standpoint,  with  a  much  larger  and  more  impor- 
tant class,  best  epitomized  by  the  term  asthenopia,  in  which 
photophobia,  irritability,  and  want  of  endurance  of  the 
ciliary  muscle,  accommodative  asthenopia,  or  sometimes  of 
the  internal  recti,  muscular  asthenopia,  with  some  conjunc- 
tival irritability,  are  the  main  symptoms,  acuteness  of  sight 
being  usually  perfect,  and  the  refraction  nearly  or  quite 
normal.  Of  the  retinal,  conjunctival,  and  muscular  fac- 
tors, any  one  may  be  more  marked  than  the  others,  and  it 
would  seem  that,  given  a  certain  state  of  the  nervous  sys- 
tem, which  may  be  described  as  impressionable  or  hyper- 
aesthetic,  over-stimulation  of  any  one  is  liable  to  set  up  an 
over-sensitive  state  of  the  other  two.  These  patients  often 
complain  also  of  dazzling,  pain  at  the  back  of  the  eyes, 
and  headache  or  neuralgia  in  the  head.  All  the  symptoms 
are  worse  after  the  day's  work,  and  sometimes  on  first 
waking  in  the  morning,  and  they  are  liable  to  vary  much 
with  the  health.  Artificial  light  always  aggravates  them, 
because  it  is  often  flickering  and  insufficient,  but  especially 
because  it  is  hot.  The  symptoms  often  last  for  months  or 
years,  causing  great  discomfort  and  serious  loss  of  time. 

Causation. — The  patients  are  seldom  children  or  old 
people.  Most  are  women,  either  young  or  not  much  past 
middle  life,  often  very  excitable,  and  often  with  feeble  cir- 
culation. If  men,  they  are  emotional,  fussy,  and  often 
hypochondriacal.     Some   cause,    such   as   prolonged   and 

12* 


^74  AMBLYOPIA. 

intense  application  at  needlework  or  reading,  can  often  be 
traced,  and  in  such  cases  the  symptoms  may  come  on  so 
suddenly  that  the  patient  becomes  within  a  few  hours  or  a 
day  or  two  quite  incapacitated  for  reading.  Sometimes 
bright  colors,  glittering  things,  or  exposure  to  kitchen  fire, 
seems  especially  injurious.  Or,  again,  there  is  a  history  of 
phlyctenular  ophthalmia,  or  superficial  ulcers,  which  have 
left  the  fifth  nerve  permanently  unstable.  Accommodative 
asthenopia  with  hypermetropia  or  astigmatism  is  at  the 
bottom  of  nearly  all  the  cases  in  which  vision  is  supposed 
to  have  been  injured  by  railway  and  other  accidents;  the 
lowered  tone  caused  by  the  shock  is  often  more  apparent 
in  the  ciliary  muscle  because  this  muscle  is  in  almost  con- 
stant action  and  has  no  substitute. 

Treatment. — The  refraction  and  the  state  of  the  in- 
ternal recti  should  always  be  carefully  tested,  and  any  error 
corrected  by  lenses,  which  may  often  be  combined  with 
prisms,  with  their  bases  toward  the  nose.  Plain  colored 
glasses  are  sometimes  useful.  But  glasses  will  not  cure  the 
disease,  and  w^e  must  not  promise  too  much  from  their  use. 
The  patient  ma}^  be  assured  that  there  is  no  ground  for 
alarm,  and  that  the  symptoms  will  probably  pass  off  sooner 
or  later.  He  should  be  discouraged  from  thinking  about 
his  eyes,  and  he  need  seldom  be  quite  idle.  The  artificial 
light  used  should  be  sufficient  and  steady,  not  flickering, 
and  should  be  shaded  to  prevent  the  heat  and  light  from 
striking  directly  on  the  eyes.  Bathing  the  eyes  freely  wath 
cold  w^ater,  and  the  occasional  employment  of  weak  astrin- 
gent lotions,  are  useful,  and  cold  air  often  acts  beneficially. 
The  eyes  are  often  much  better  after  a  day  or  two.  Out- 
door exercise,  and  only  moderate  use  of  the  eyes,  therefore, 
should  be  enjoined.  General  measures  must  be  taken  ac- 
cording to  the  indications,  especially  in  reference  to  any 
ovarian,  uterine,  or  digestive  troubles,  or  to  sexual  ex- 
haustion in  men. 


functional   diseases   of   the   retina.     275 

Functional  Diseases  of  the  Retina. 

Functional    night-blindness    (endemic    nyctalopia)    is 

caused  by  temporary  exhaustion  of  the  retinal  sensibility 
from  prolonged  exposure  to  diffused,  bright  light.  The 
circumstances  under  which  it  occurs  usually  imply  not 
only  great  exposure  to  bright  light,  but  lowered  general 
nutrition,  and  probably  some  defect  in  diet.  It  often  co- 
exists with  scurvy.  Sleeping  with  the  face  exposed  to  bright 
moonlight  is  believed  to  bring  it  on.  It  is  commonest  in 
sailors  after  long  tropical  voyages  under  bad  conditions,*and 
in  soldiers  after  long  marching  in  bright  sun.  In  some 
countries  it  prevails  every  year  in  Lent  when  no  meat  is 
eaten,  and  again  in  harvest-time.  It  is  now  but  rarely  en- 
demic in  our  country,  but  scattered  cases  occur,  especially 
in  children,^  and  it  still  occasionally  prevails  in  large 
schools. 

In  this  malady  two  little  dry  films,  consisting  of  fatty  or 
sebaceous  matter  and  epithelial  scales,  often  form  on  the 
conjunctiva  at  the  inner  and  outer  border  of  the  cornea. 
Their  meaning  is  obscure.  There  are  no  ophthalmoscopic 
changes.  This  night-blindness  is  soon  cured  by  protection 
from  bright  light  and  improvement  of  health,  and  espe- 
cially by  cod-liver  oil.  That  the  affection  is  local  in  the 
eye  is  shown  by  the  fact  that  darkening  one  eye,  with  a 
bandage,  during  the  day,  has  been  found  to  restore  its  sight 
enough  for  the  ensuing  night's  watch  on  board  ship,  the 
unprotected  eye  remaining  as  bad  as  ever.  Snow-blindness 
or  ice-blindness  is  essentially  the  same  disease,  with  the  ad- 
dition of  congestion,  intense  pain,  photophobia,  contraction 
of  pupils,  and  sometimes  of  conjunctivalecchymoses.  These 

^  Snell  reports  numerous  cases  from  near  SheflBeld.  Transactions  of 
the  Ophthalmological  Society,  vol.  i.,  18S1.  Since  Mr.  Snell  drew  at- 
tention to  this  subject  I  have  seen  several  cases,  all  of  them  (as  were 
most  of  Snell's)  in  the  springer  early  summer. 


li  7  0       FUNCTIONAL     DISEASES     OF     THE     RETINA. 

peculiarities  doubtless  depend  chiefly  on  powerful  and  pro- 
longed stimulation  of  the  whole  retina,  leading  to  conges- 
tion of  its  own  vessels  and  those  of  the  choroid,  and  subse- 
quently of  the  whole  eyeball ;  something  may  also  be  due 
to  the  effect  of  the  reflected  heat  upon  the  conjunctiva. 
Snow-blindness  is  effectually  prevented  by  wearing  smoke- 
colored  glasses.  Attacks,  apparently  identical  with  snow- 
blindness,  but  of  shorter  duration,sometimesoccur  in  men 
engaged  in  trimming  powerful  electric  lights.  The  symp- 
toms do  not  come  on  until  several  hours  after  exposure  to 
the  light.' 

Hemeralopia  (day-blindness)  occurs  in  certain  cases  of 
congenital  amblyopia. 

Colored  vision  is  sometimes  complained  of,  and  red  is 
tbe  color  usually  noticed.  Red  vision  (Erythropsia)  is 
most  common  some  time  after  extraction  of  senile  cataract, 
and  is  associated  with  fatigue  ;  everything  looks  rosy  red, 
"as  if  there  was  a  most  beautiful  sunset,"  as  one  patient 
said.  Overw^orked,  anxious,  neurotic  children  sometimes 
complain  that  after  reading  or  sewing  "everything  turns 
red"  or  "  red  and  blue."  I  have  not  heard  green  or  yellow 
mentioned.  It  has  also  been  seen  in  women  much  exhausted 
by  fasting. 

Micropsia.  Patients  sometimes  complain  that  objects 
look  too  small.  When  not  due  to  insufficiency  of  accommo- 
dative power  it  is  generally  a  symptom  of  disease  of  the 
outer  layers  of  the  retina,  especially  in  the  central  region, 
and  syphilitic  retinitis  is  the  commonest  cause.  Both 
micropsia  and  its  opposite,  megalopsia,  are  sometimes  seen 
in  hysterical  amblyopia. 

By  muscae  volitantes  are  understood  small  dots,  rings, 
threads,  etc.,  which  move  about  in  the  field  of  vision,  but 
do  not  actually  cross  the  fixation  point,  and  never  interfere 

1  Opbtlialmic  Review,  April,  18S3. 


DIPLOPIA  —  MALINGERING.  277 

with  sight.  They  are  most  easily  seen  against  the  sky,  or 
a  bright  background  such  as  the  microscope  field.  They 
depend  upon  minute  changes  in  the  vitreous,  which  are 
present  in  nearly  all  eyes,  though  in  much  greater  quantity 
in  some  than  others.  They  vary,  or  seem  to  vary,  greatly 
with  the  health  and  state  of  the  circulation,  but  are  of  no 
real  importance.  They  are  most  abundant  and  trouble- 
some in  myopic  eyes. 

Diplopia,  see  Chap.  XXI.  ;  also  pp.  60  and  195  for  Uni- 
ocular  Diplopia. 

For  affections  of  sight  in  Megrim  and  Heart  Disease, 
see  Chap.  XXII. 

Malingering,  Patients  now  and  then  pretend  defect  or 
blindness  of  one  or  both  eyes,  or  exaggerate  an  existing 
defect,  or  sometimes  secretly  use  atropine  in  order  to  dim 
the  sight.  The  imposture  is  generally  evident  enough  from 
other  circumstances,  but  detection  is  occasionally  very  diffi- 
cult. Malingering  and  intentional  injuries  of  the  eye  are 
very  rare  here,  but  common  in  countries  where  the  con- 
scription is  in  force. 

The  pretended  defect  of  sight  is  usually  confined  to  one 
eye.  If  the  patient  be  in  reality  using  both  eyes,  a  prism 
held  before  one,  by  preference  the  ''  blind  ''  one,  will  pro- 
duce double  vision.  The  stereoscope,  and  also  colored 
glasses,  may  be  made  very  useful.  Another  test,  when  only 
moderate  defect  is  asserted,  is  to  try  the  eye  with  various 
weak  glasses,  and  note  whether  the  replies  are  consistent; 
very  probably  a  flat  glass  or  a  weak  concave  may  be  said 
to  "improve"  or  "magnify"  very  much.  Again,  atropine 
may  be  put  into  the  sound  eye,  and  when  it  has  fully  acted 
the  patient  be  asked  to  read  small  print;  if  he  reads  easily 
with  both  eyes  open  the  imposture  is  clear,  for  he  must  be 
reading  with  the  so-called  "blind"  eye.  If  absolute  blind- 
ness of  one  eye  be  asserted,  the  state  of  the  pupil  will  be 
of  much  help,  unless  the  patient  have  used  atropine;  for 


278       FUNCTIONAL     DISEASES     OF     THE     RETINA. 

if  its  direct  reflex  action  be  good,  the  retina  and  ner^e 
cannot  be  much  diseased. 

Pretended  defect  of  both  eyes  is  more  difficult  to  expose, 
and,  indeed,  it  may  be  impossible  absolutely  to  convict  the 
patient  if  he  be  intelligent  and  instructed.  The  state  of 
the  pupils,  of  the  visual  fields,  and  of  color  perception  are 
amongst  the  best  tests. 

Color-blindness  may  be  congenital  or  acquired.  When 
acquired  it  is  symptomatic  of  disease  of  the  optic  nerve,  or 
as,  for  example,  in  hysterical  amblyopia,  of  some  affection 
of  the  visual  centre. 

Congenital  color-blindness  is   not   often    found   unless 
looked   for.     According  to  recent  and  extended  researches 
in  various  countries,  a  proportion  varying  from  about  3  to 
5  per  cent,  of  the  males  are  color-blind  in  greater  or  less 
degree,  and  it  appears  to  be  more  common  in  the  lower 
than  in  the  upper  classes.     These  facts  show  the  impor- 
tance of  carefully  testing  all  men  whose  employment  ren- 
ders good  perception  of  color  indispensable,  such  as  railway 
signalmen  and  sailors.     Color-blindness  is  usually  partial, 
i.  e.  for  only  one  color  or  one  pair  of  complementary  colors, 
but  is  occasionally  total.     The  commonest  form  is  that  in 
which  pure  green  is  confused  with  various  shades  of  gray 
and  of  red  (red-green  blindness) ;  blindness  for  blue  and 
yellow^  is  very  rare.     The  blindness  may  be  incomplete, 
perception  of  very  pale,  or  very  dark,  red  or  green,  i.  e., 
being  enfeebled,  whilst  bright  red  and  green  are  well  recog- 
nized ;  or  it  may  be  complete  for  all  shades  and  tints  of 
those   colors.      Congenital   color-blindness  is  very  often 
hereditary,  but  nothing  further  is  know^n  of  its  cause.     It 
is  very  rare  in  women  (0.2  per  cent.).     The  acuteness  of 
vision,  i.  e.,  perception  of  form,  is  normal.    Both  eyes  are 
aftected.^ 

^  But  ou  this  point  further  research  is  needed. 


COLOR-BLINDNESS.  279 

The  detection  of  color-blindness,  either  congenital  or 
acquired,  is  easy,  if,  in  making  the  examination,  we  bear 
in  mind  the  two  points  already  referred  to  at  p.  -47,  viz.: 
( 1 )  Many  persons  with  perfect  color  perception  know  very 
little  of  the  names  of  colors,  and  appear  color-l^lind  if 
asked  to  name  them  ;  (2)  the  really  color-blind  often  do 
not  know  of  their  defect,  having  learned  to  compensate  for 
it  by  attention  to  differences  of  shade  and  texture.  Thus, 
a  signalman  may  be  color-blind  for  red  and  green ;  yet  he 
may,  as  a  rule,  correctly  distinguish  the  green  from  the  red 
light,  because  one  appears  to  him  "  brighter  "  than  the 
other.  The  quickest  and  best  way  of  a  voiding  these  sources 
of  error  has  been  mentioned  at  p.  47.  A  certain  standard 
color  is  given  to  the  patient  without  being  named,  and  he 
is  asked  to  choose  from  the  whole  mass  of  skeins  of  wool 
all  that  appear  to  him  of  nearly  the  same  color  and  shade 
(no  two  being  really  quite  alike).  If,  for  example,  he  can- 
not distinguish  green  from  red,  he  will  place  the  green  test- 
skein  side  by  side  with  various  shades  of  gray  and  red. 
Wilful  concealment  of  color-blindness  is  impossible  under 
this  test  if  a  suflBcient  number  of  shades  be  used. 

As  it  is  necessary  to  detect  slight  as  well  as  high  degrees, 
the  first  or  preliminary  test  should  consist  of  very  pale 
colors,  and  a  pale  pure  green  is  to  be  taken  as  the  test 
No.  I.  (see  plate  in  the  Appendix) ;  Xos.  1  to  5  are  liable  to 
be  confused  with  this  color.  For  ascertaining  whether  the 
defect  be  of  higher  degree  or  not,  stronger  colors  are  then 
used  ;  a  bright  rose  color,  e.  g.,ll.  a,  may  be  confused  with 
blue,  purple,  green,  or  gray  of  corresponding  depth  (Xos. 
6  to  9);  and  a  scarlet,  II.  b,  with  various  shades  and  tints 
of  brown  and  green  (Xos.  10  to  13). 

It  may  here  be  noted  that  the  visual  field  is  not  of  the 
same  size  for  all  colors,  Fig.  22,  green  and  red  having  the 
smallest  fields,  and  that  the  perception  of  all  colors  is,  like 
perception   of  form,  sharpest  at  the  centre  of  the    field. 


280       FUNCTIONAL     DISEASES     OF     THE     RETINA. 

With  diminished  illumination  some  colors  are  less  easily 
perceived  than  others,  red  being  the  first  to  disappear,  and 
blue  persisting  longest,  i.  e.,  being  perceived  under  the 
lowest  illumination  ;  but  in  dull  light  the  colors  are  not 
confused,  as  in  true  color-blindness.  In  congenital  color- 
blindness, as  we  have  seen,  red-green  blindness  is  the  com- 
monest form  ;  and  in  cases  of  amblyopia  from  commencing 
atrophy  of  the  optic  nerve,  green  and  red  are  almost  al- 
ways the  first  colors  to  fail,  blue  remaining  last. 


CHAPTER    XYI. 

DISEASES    OF    THE    VITREOUS. 

The  vitreous  humor  is  nourished  by  the  vessels  of  the 
ciliary  body,  retina,  and  optic  disc,  and  is  probably  influ- 
enced by  the  state  of  the  choroid  also ;  and  in  most  cases 
disease  of  the  vitreous  is  associated  with,  and  dependent  oh, 
disease  of  one  or  other  of  the  structures  named. 

Thus,  in  connection  with  various  surrounding  morbid 
processes,  the  vitreous  may  be  the  seat  of  inflammation, 
acute  or  chronic,  general  or  local,  and  of  hemorrhage.  It 
may  also  degenerate,  especially  in  old  age  ;  its  cells  and 
solid  parts  undergoing  fatty  change,  become  visible  as 
opacities,  whilst  its  general  bulk  becomes  too  fluid.  The 
only  alteration  that  we  can  directly  prove  in  the  vitreous 
during  life  is  loss  of  transparency,  from  the  presence  of 
opacities  moving,  or  more  rarely  fixed,  in  it,  but  according 
as  such  opacities  move  quickly  or  slowly  we  infer  that  the 
humor  itself  is,  or  is  not,  more  fluid  than  in  health. 

Opacities  in  the  vitreous  may  take  the  form  of  large 
dense  masses,  or  of  membranes,  like  muslin,  crape,  "  bees' 
wings"  of  wine,  bands,  knotted  strings,  or  isolated  dots ; 
and  the3^may  be  either  recent  or  the  remains  of  long  ante- 
cedent exudation,  hemorrhage,  or  degeneration,  or  newly- 
formed  bloodvessels.  Again,  the  vitreous  may  become 
uniformly  misty,  owing  to  the  diffusion  of  numberless  dots, 
"dust-like"  opacities,  which  need  careful  focussing  by 
direct  examination  with  a  convex  lens  (about  +  12  D.) 
behind  the  mirror  to  be  separately  seen. 

Opacities  in  the  vitreous  are  usuallv  detected  with  great 


282  DISEASES    OF     THE     VITREOUS. 

ease  by  direct  ophthalmoscopic  examination  at  about  12'' 
from  the  patient,  but  are  generally  situated  too  far  forward, 
i.  e.,  too  far  within  the  focus  of  the  lens  system,  to  be  seen 
clearly  at  a  very  short  distance  without  a  +  lens  behind 
the  mirror.  If  the  patient  move  his  eye  sharply  and  freely 
from  side  to  side  and  from  above  downward,  the  opacities 
will  be  seen  against  the  red  ground  as  dark  figures  which 
continue  to  move  after  the  eye  has  come  to  rest ;  they  are 
thus  at  once  distinguished  from  opacities  in  the  cornea  or 
lens,  or  from  dimly  seen  spots  of  pigment  at  the  fundus 
which  stop  when  the  eye  stops.  The  opacities  in  the  vit- 
reous move  just  as  solid  particles  and  films  move  in  a  bottle 
after  the  bottle  has  been  shaken ;  the  quickness  and  free- 
dom of  their  movement  in  the  one  case,  as  in  the  other, 
depending  very  much  on  the  consistence  of  the  fluid. 
When  the  opacities  pass  across  the  field  quickly  and  make 
wide  movements,  we  may  be  sure  that  there  is  synchi/sis  or 
fluidity  of  the  vitreous  humor;  if  they  move  very  lazily, 
its  consistence  is  probably  normal ;  if  only  one  or  two 
opacities  be  present,  they  may  only  come  into  view  now 
and  then.  Moving  opacities  in  the  vitreous  obscure  the 
fundus  both  to  the  direct  and  indirect  ophthalmoscopic 
examination,  in  proportion  to  their  size,  density,  and  posi- 
tion ;  a  few  isolated  dots  scarcely  afi"ect  the  brightness  of  the 
ophthalmoscopic  image. 

The  opacities  may  lie  quite  in  the  cortex  of  the  vitreous 
and  be  anchored  at  the  fundus,  so  as  to  have  but  little 
movement.  Such  opacities,  generally  single,  are  found 
lying  over  or  near  to  the  disc,  and  may  be  the  result  either 
of  inflammation  or  of  hemorrhage ;  they  are  often  mem- 
branous, more  rarely  globular,  and  not  perfectly  opaque. 
Such  an  opacity  should  be  suspected  v/hen,  by  indirect 
ophthalmoscopic  examination,  a  localized  haze  or  blurring 
of  some  part  of  the  disc  or  its  neighborhood  is  noticed. 
The  opacity  must  then  be  searched  for  by  the  direct  method, 


DISEASES     OF    THE     VITREOUS.  283 

the  patient's  eye  being  at  rest ;  by  altering  the  distance 
from  the  patient,  or  by  turning  on  various  convex  lenses 
(or  concave,  if  the  eye  be  very  highly  myopic),  the  opacity 
will  come  sharply  into  view.  The  patient's  refraction  must 
be  approximately  known  in  order  to  make  this  examina- 
tion properly.  Densely  opaque  white  membranes  may 
also  form  over  the  disc  or  upon  the  retina,  the  nature  and 
situation  of  which  are  diagnosed  in  the  same  way. 

Diffused  haziness  of  the  vitreous  causes  a  corresponding 
degree  of  dimness  of  outline  and  darkening  of  the  details 
of  the  fundus  as  if  these  were  seen  through  a  thin  smoke. 
The  disc  in  particular  appears  red,  without  really  being 
so.  Much  the  same  appearances  are  caused  by  diffused 
haze  of  the  cornea  or  lens,  but  the  presence  of  these  changes 
will,  of  course,  have  been  excluded  by  focal  illumination. 
There  are  even  cases  of  vitreous  disease  where  no  details 
can  be  seen,  even  by  careful  examination,  though  plenty 
of  light  reaches  and  returns  from  the  fundus.  In  these 
the  light  is  scattered  by  innumerable  little  particles,  each  of 
which  is  transparent,  so  that  the  light,  without  being  ab- 
sorbed, is  distorted  and  broken  up,  as  in  passing  through 
ground-glass  or  white  fog  or  a  partial  mixture  of  fluids 
of  different  densities,  such  as  glycerine  and  water.  This 
fine  general  haze  is  found  chiefly  in  syphilitic  choroido- 
retinitis,  in  which  infiltration  of  the  vitreous  with  cells  is 
known  to  occur.  It  is  not  always  easy,  nor  indeed  possi- 
ble, to  distinguish  with  certainty  between  diffuse  haze  of 
the  vitreous  and  diffuse  haze  of  the  retina. 

Crystals  of  cholesterin  sometimes  form  in  a  fluid  vitreous 
and  are  seen  with  bright  illumination  as  minute,  dancing, 
golden  spangles,  when  the  eye  moves  about,  sparkling  syn- 
chysis.  They  proportionately  obscure  the  fundus.  Large 
opacities  just  behind  the  lens  may  be  seen  by  focal  light  in 
their  natural  colors.  In  rare  cases  of  choroido-retinitis, 
minute  growths  consisting  chiefly  of  bloodvessels,  form  on 


284  DI8EA8ES     OF     THE     VITREOUS. 

the  retina  and  project  into  the  vitreous ;  they  are  rather 
curiosities  than  of  practical  importance. 

Parasites  (cysticercns  cellulosae)  occasionally  come  to 
rest  in  the  eye,  and  in  development  penetrate  into  the  vitre- 
ous ;  they  are  rarely  seen  in  England,  but  are  compara- 
tively common  in  some  parts  of  Germany.  Very  rarely  a 
foreign  body  may  be  visible  in  the  vitreous. 

The  following  are  the  conditions  in  which  disease  of  the 
vitreous  is  most  commonly  found  : 

(1.)  Myopia  of  high  degree  and  old  standing ;  the  opaci- 
ties move  very  freely,  showing  fluidity  of  the  humor,  and 
are  sharply  defined.  They  are  often  the  result  of  former 
hemorrhage. 

(2.)  After  severe  blows,  causing  hemorrhage  from  the 
vessels  of  the  choroid  or  ciliary  body.  When  recent,  and 
situated  near  the  back  of  the  lens,  the  blood  can  often  be 
seen  by  focal  light ;  if  very  abundant  it  so  darkens  the 
interior  of  the  eye  that  nothing  whatever  can  be  seen  with 
the  mirror. 

(3.)  After  perforating  wounds.  The  opacity  will  be 
blood  if  the  case  be  quite  recent.  Lymph  or  pus  in  the 
vitreous  gives  a  yellow  or  greenish-yellow  color,  easily  seen 
by  focal  light,  or  even  by  daylight,  and  usually  most  dense 
toward  the  position  of  the  wound. 

(4.)  In  rare  cases  large  hemorrhages  into  the  vitreous 
occur  spontaneously  in  healthy  eyes,with  hemorrhages  into 
the  retina  (not  to  be  confused  with  retinitis  haemorrhagica). 
Relapses  often  occur,  and  detachment  of  retina  may  ensue. 
The  subjects  are  generally  young  adult  males  liable  to 
epistaxis,  constipation,  and  irregularity  of  circulation 
(Eales);  gout  may  have  some  influence  (Hutchinson). 
This  affection  seems  sometimes  to  be  related  with  the  form 
of  choroiditis  referred  to  at  p.  222. 

In  all  of  the  above  cases  detachment  of  the  retina  is 


DISEASES    OF    THE     VITREOUS.  285 

likely  to  occur  sooner  or  later,  and  if  both  be  present  the 
differential  diagnosis  may  be  difficult. 

(5.)  Syphilitic  choroiditis  and  retinitis.  There  is  often 
diffuse  haze  in  addition  to  large,  slowly  floating  opacities. 
The  change  here  is  due  to  inflammation,  and  the  opacities 
may  entirely  disappear  under  treatment.  These  are  the 
cases  in  which  new  vessels  in  the  vitreous  are  most  common. 

(6.)  Some  cases  of  cyclitis  and  cyclo-iritis.  The  opaci- 
ties are  inflammatory. 

(7.)  In  the  early  stage  of  sympathetic  ophthalmitis.  The 
opacities  are  inflammatory. 

(8.)  In  various  cases  of  old  disease  of  choroid,  usually 
in  old  persons,  and  without  proof  of  syphilis.  No  doubt 
many  of  these  indicate  former  choroidal  hemorrhages. 

(9.)  Cases  occur  in  which  no  cause,  either  local  or  gen- 
eral, can  be  assigned  for  the  presence  of  opacities  in  the 
vitreous. 


CHAPTER    XYII. 

GLAUCOMA. 

In  this  peculiar  and  very  serious  disease  the  character- 
istic objective  symptom  is  increased  tightness  of  the  eye- 
capsule,  sclerotic  and  cornea,  "increased  tension;"  all  the 
characteristic  features  of  the  disease  depend  upon  this. 
The  disease  is  much  commoner  after  middle  life,  when 
the  sclerotic  becomes  less  distensible  than  before;  and  it  is 
commoner  in  hypermetropic  eyes,  where  the  sclerotic  is 
too  thick,  than  in  myopic  eyes,  where  it  is  thinned  by 
elongation  of  the  globe. 

Glaucoma  may  be  primary,  coming  on  in  an  eye  appa- 
rently healthy,  or  the  subject  of  some  disease,  such  as  senile 
cataract,  which  has  no  influence  on  the  glaucoma;  or  it  may 
be  secondary,  caused  by  some  still  active  disease  of  the 
eye,  or  by  conditions  left  after  some  previous  disease,  such 
as  iritis.  It  is  always  important,  and  seldom  difficult,  to 
distinguish  between  primary  and  secondary  glaucoma. 

Glaucoma  differs  in  severity  and  rate  of  progress  from 
the  most  acute  to  the  most  chronic  and  insidious  form  ; 
but  in  every  form  it  is  a  progressive  disease,  and  unless 
checked  by  treatment  goes  on  to  permanent  blindness. 
The  disease  is  very  often  symmetrical,  attacking  the  second 
eye  after  an  interval  which  varies. 

It  is  customary  and  useful  to  speak  of  glaucoma  as  either 
acute,  subacute,  or  chronic.  But  many  intermediate  forms 
are  found,  and  the  same  eye  may,  at  different  stages  in  its 
history,  pass  through  each  of  the  three  conditions.  We 
mav,  indeed,  here  observe  that  acute  and  subacute  outbursts 


GLAUCOMA.  287 

are  generally  preceded  by  a  so-called  "premonitory"  stage, 
in  which  the  symptoms  are  not  only  chronic  and  mild,  but 
remittent ;  the  intervals  of  remission  becoming  shorter  and 
shorter,  till  at  length  the  attacks  become  continuous,  and 
the  glaucomatous  state  is  fully  established.  Rapid  increase 
of  presbyo})ia  (Chap.  XX.),  shown  by  the  need  for  a  fre- 
quent change  of  spectacles,  is  a  common  premonitory  sign, 
though  often  overlooked. 

Chronic  glaucoma  sets  in  with  a  cloudiness  of  sight,  or 
"fog,"  varying  in  density,  and  often  clearing  off  entirely 
for  days  and  even  weeks,  "premonitory  stage."  But,  in 
some  cases,  according  to  the  patient,  the  failure  progresses 
without  remissions  from  first  to  last.  During  the  attacks 
of  "fog,"  artificial  lights  are  seen  surrounded  by  colored 
rings,  "rainbows"  or  "halos,"  due  to  haze  of  the  cornea, 
which  are  to  be  distinguished  from  those  due  to  mucus  on 
the  cornea.  The  attacks  of  fog  are  often  noticed  onl}^  after 
long  use  of  the  eyes,  as  in  the  evening  or  when  exhausted, 
the  sight  being  better  in  the  early  part  of  the  day  and  after 
food.  Even  when  the  sight  has  become  permanently 
cloudy,  complete  recovery  no  longer  occurring  between  the 
attacks,  variations  of  sight  still  form  a  marked  feature. 
There  is  no  congestion,  and  pain  of  neuralgic  character, 
though  not  uncommon,  is  often  entirely  wanting.  The  dis- 
ease has  to  be  distinguished  from  incipient  nuclear  cataract, 
disease  of  the  optic  nerve,  syphilitic  retinitis,  and  attacks  of 
megrim. 

If  we  see  the  patient  during  one  of  the  brief  early  fits  of 
cloudy  sight,  or  after  the  fog  has  settled  down  permanently, 
the  following  changes  will  be  found.  A  greater  or  less 
defect  of  sight  in  one  eye,  or  if  in  both,  more  in  one  than 
the  other,  and  not  remedied  by  glasses;  the  pupil  a  little 
larger  and  less  active  than  normal ;  the  anterior  chamber 
may  be  shallow,  and  there  is  usually  slight  dulness  of  the 
eye  from  steaminess  of  cornea,  or   haze  of  the  aqueous 


288  GLAUCOMA. 

humor,  and  some  engorgement  of  the  large  perforating 
vessels  at  a  little  distance  from  the  cornea ;  the  tension 
somewhat  increased,  usually  about  -f  1,  p.  43  ;  and  the 
field  of  vision  may  be  contracted,  especially  on  the  nasal 
side.  The  optic  disc  will  be  found  normal,  pale,  or  some- 
times congested,  in  early  cases ;  pale  and  cupped  all  over 
at  a  later  stage.  There  may  be  spontaneous  pulsation  of 
all  the  vessels  on  the  disc ;  or  the  arteries,  if  not  pulsating 
spontaneously,  will  do  so  on  very  slight  pressure  on  the  eye- 
ball. In  old  standing  cases  the  tension  will  often  be  much 
increased,  the  pupil  dilated  and  sluggish,  though  not  mo- 
tionless, the  lens  hazy,  the  field  of  vision  much  contracted, 
Fig.  94,  acateness  of  vision  extremely  defective,  the  cornea 
sometimes  clear,  in  other  cases  dull.  In  nearly  all  cases  of 
glaucoma  the  temporal  part  of  the  field,  nasal  part  of  the 
retina,  retains  its  function  longest ;  and  in  advanced  cases 
the  patient  will  often  show  this  by  his  manner  or  state- 
ments; occasionally  the  field  becomes  extremely  contracted 
before  central  vision  fails.  In  some  few  cases  of  simple 
glaucoma  scotomata  appear  at  the  central  part  of  the 
field  without  contraction. 

An  eye  in  which  the  above  symptoms  have  set  in  may 
progress  to  total  blindness  in  the  course  of  months  or 
several  years  without  a  single  "inflammatory"  symptom, 
without  either  pain  or  redness — chronic  painless  glaucoma 
{glaucoma  simplex)-^  and  since  the  lens  often  becomes  par- 
tially opaque,  and  of  a  grayish  or  greenish  hue,  cases 
of  chronic  glaucoma  are  sometimes  mistaken  for  senile 
cataract. 

But  more  comnionh^,  in  the  course  of  a  chronic  case, 
periods  of  pain  and  congestion  occur,  with  more  rapid 
failure  of  sight ;  or  the  disease  sets  in  with  "  inflammatory" 
symptoms  at  once.  In  these  cases  of  subacute  glaucoma, 
besides  the  symptoms  named  above,  we  find  dusky,  reticu- 
lated congestion  of  the  small  and  large  episcleral  vessels  in 


GLAUCOMA.  289 

the  ciliary  region,  with  pain  referred  to  the  eye,  the  side  of 
the  head  or  of  the  nose,  and  rapid  failure  of  sight.  The 
increase  of  tension,  steaniiness,  and  partial  anesthesia  of  the 
cornea,  enlarged  and  sluggish  pupil,  and  shallowness  of  the 
anterior  chamber,  are  all  more  marked  than  is  usual  in 
chronic  cases,  and  the  media  are  too  hazy  to  allow  a  good 
ophthalmoscopic  examination. 

Fig.   94-. 


Irresfular  contraction  ofR.  andL.  fieldsof  vision  iu  chronic  glaucoma; 
from  two  different  cases.  The  black  parts  show  complete  loss ;  the 
shaded  area  shows  partial  loss.  Each  field  remains  best  in  the  outer 
part.     (Compare  with  Figs.  90  and  91.) 

These  symptoms,  ending  after  a  few  weeks  or  months  in 
complete  blindness,  may  remain  at  about  the  same  height 
for  months  after  that  event,  with  slight  variations,  the  eye 
gradually  settling  down  into  a  permanent  state  of  severe, 
but  chronic,  non-inflammatory  glaucomatous  tension. 
Short  attacks  of  subacute  glaucoma,  with  intervals  of 
perfect  recovery,  sometimes  occur,  i^emittent  glaucoma; 
permanent  glaucoma  usually  supervenes. 

Acute  glaucoma  differs  from  the  other  forms  only  in 
suddenness  of  onset,  rapidity  of  loss  of  sight,  and  severity 
of  congestion  and  pain.  The  congestion,  both  arterial  and 
venous,  is  intense  ;  in  extreme  cases  the  lids  and  conjunc- 
tiva are  swollen,  and  there  is  photophobia,  so  that  the  case 
may  be  mistaken  for  an  acute  ophthalmia.      All  the  specific 

13 


290  GLAUCOMA. 

signs  of  glaucoma  are  intensified;  the  pupil  considerably 
dilated  and  motionless  to  light,  the  cornea  very  steamy,  the 
anterior  chamber  very  shallow,  and  tension  -f  2  or  3. 
Sight  will  fall  in  a  day  or  two  down  to  the  power  of  only 
counting  fingers,  or  to  mere  perception  of  light,  and  if 
the  case  have  lasted  a  week  or  two,  even  p.  1.  is  usually 
abolished.  The  pain  is  very  severe  in  the  eye,  temple, 
back  of  the  head,  and  down  the  nose;  not  unfrequently  it 
is  so  bad  as  to  cause  vomiting,  and  many  a  case  has  been 
mistaken  for  a  "bilious  attack"  with  a  "cold  in  the  eye," 
for  "neuralgia  in  the  head,"  or  "rheumatic  ophthalmia." 
Some  cases,  however,  though  very  acute,  are  mild  and 
remit  spontaneously  ;  but  these,  like  the  ones  mentioned  in 
the  preceding  paragraph,  often  pass  on  to  the  severe  type 
now  described. 

Absolute  glaucoma  is  glaucoma  that  has  gone  on  to  per- 
manent blindness.  Such  an  eye  continues  to  display  the 
tension  and  other  signs  of  the  disease,  and  remains  liable 
to  attacks  of  pain  and  congestion  for  varying  periods,  but 
in  many  "  absolute"  cases,  especially  when  the  original 
attack  was  acute,  changes  occur  sooner  or  later,  leading  to 
staphylomata,  cataract,  atrophy  of  iris,  and  finally  to  soften- 
ing and  shrinkage  of  the  globe. 

As  a  rule,  glaucoma  runs  the  same  course  in  the  second 
eye  as  in  the  first,  but  sometimes  it  will  be  chronic  in  one 
and  acute  or  subacute  in  the  other. 

Explanation  of  the  Symptoms. — The  causes  which 
produce  the  temporary  attacks  or  "premonitory  symptoms" 
lead,  if  continued,  to  atrophy  of  the  inner  layers  of  the 
retina  and  of  the  disc,  and  to  consequent  blindness.  The 
increase  of  tension  damages  the  retina  both  by  direct  com- 
pression and  by  impeding  its  circulation,  the  latter  being 
probabl}^  the  more  important  factor  in  the  early  stages.  If 
the  media  be  clear  enough  to  allow  a  good  view,  the  retinal 
arteries  are  seen  to  be  narrow,  and  often  pulsating  spontane- 


GLAUCOMA 


291 


ously,  and  the  veins  engorged.  The  periphery  of  the  retina 
suffers  soonest  and  most  from  this  lowering  of  arterial  blood 
supply,  and  hence  probably  the  contraction  of  the  visual 
field  ;  but  the  inner  layers  of  the  retina,  over  its  whole  ex- 
tent, suffer  if  the  pressure  be  kept  up — (1)  from  this  same 
insufficiency  of  arterial  blood,  and  the  changes,  including 
hemorrhage,  which  follow  impeded  venous  outflow  ;  (2) 
from  direct  compression  of  the  retina  ;  (3)  from  stretching 
and  atrophy  of  the  nerve-fibres  on  the  disc.  The  floor  of 
the  disc,  lamina  cribrosa,  being  the  weakest  part  of  the  eye- 
capsule,  is  slowly  pressed  backward,  the  nerve-fibres  being 
dragged  upon,  displaced,  and  finally  atrophied  ;  the  direct 
pressure  on  the  nerve-fibres,  as  they  bend  over  the  edge  of 
the  disc,  helps  in  the  same  process.  Hence  finally  the  disc 
becomes  not  only  atrophied,  but  hollowed  out,  Fig.  95,  into 

Fig.  95. 


Section  of  very  deep  glaucoma  cup.    (Compare  Fig.  35.) 


the  well-known  ''glaucomatous  cup."  This  cup,  when 
deep,  has  an  overhanging  edge,  because  the  border  of  the 
disc  is  smaller  at  the  level  of  the  choroid  than  at  the  level 
of  the  lamina  cribrosa ;  its  sides  are  quite  steep  even  when 
the  cup  is  shallow.  Fig.  97. 

With  the  ophthalmoscope  this  cupping  is  shown  by  a 


292 


GLAUCOMA. 


sudden  bending  of  the  vessels  just  within  the  border  of  the 
disc,  where  they  look  darker  because  foreshortened,  Fig. 


Fig. 


Ophthalmoscopic  appearance  of  slig:ht  cupping  of  the  disc  in  glaucoma. 
The  disc  is  surrounded  by  a  narrow,  irregular  zone  of  atrophied  choroid. 
(Wecker  and  Jaeger.)     X  7, 

Fig.  97. 


Section  of  less  advanced  glaucoma  cup. 

96 ;  if  the  cup  be  deep  they  may  disappear  beneath  its  edge 
to  reappear  on  its  floor,  where  they  have  a  lighter  shade, 


CiLAUCOMA.  293 

Fig.  98.  The  vessels  seldom  all  bend  with  equal  abrupt- 
ness, some  parts  of  the  disc  being  more  deeply  hollowed 
than  others,  or  some  of  the  vessels  spanning  over  the  inter- 
val instead  of  hugging  the  wall  of  the  cup.  Increase  of 
tension  must  be  maintained  for  several  months  to  produce 

Fig.  98. 


Ophthalmoscopic  appearance  of  deep  cupping  of  the  disc  in  glaucoma. 
(Altered  from  Liebreich.)     X  about  15. 

cupping  recognizable  by  the  ophthalmoscope.  When  re- 
cent acute  glaucoma  has  been  cured  by  operation,  the  disc, 
though  not  cupped,  often  becomes  rather  hazy  and  very 
pale.  Although  usually  the  excavation  extends  from  the 
first  over  the  whole  surface  of  the  disc,  it  appears  sometimes 
to  begin  at  the  thinnest  part  (the  physiological  pit),  and 
spread  centrifugally  toward  the  border.  A  deep  cup  is 
sometimes  partly  filled  up  by  fibrous  tissue,  the  result  of 
chronic  inflammation,  and  its  true  dimensions  are  not  then 
appreciable  by  the  ophthalmoscope. 

The  shallowness  of  the  anterior  chamber  is  probably  due 
to  advance  of  the  lens  ;  it  is  by  no  means  a  constant  symp- 
tom.    Compression  of  the  ciliary  nerves  accounts,  in  early 


294  GLAUCOMA. 

cases,  for  the  sluggish  and  usually  dilated  pupil,  and  for  the 
corneal  anassthesia.  In  old-standing  cases  the  iris  is  often 
atrophied  and  shrunken  to  a  narrow  rim  ;  in  uncomplicated 
glaucoma  iritic  adhesions  are  never  seen.  The  corneal 
changes  depend  partly  on  ''steaminess"  of  the  epithelium, 
partly  upon  haze  of  the  corneal  tissue  from  oedema  (Fuchs). 
In  recent  cases,  especially  if  acute,  the  aqueous  humor  and 
the  lens  appear  to  become  somewhat  turbid.  In  old  cases, 
as  already  stated,  the  lens  often  becomes  slowly  cataractous. 
There  is  some  doubt  whether  or  not  the  vitreous  becomes 
hazy  in  glaucoma  ;  it  is  certainly  very  seldom  so  when  the 
cornea  and  lens  are  clear,  and  the  point  cannot  be  settled 
when  these  media  are  hazy.  The  internal  pressure  tends, 
in  acute  cases,  to  make  the  globe  spherical,  b}^  reducing  the 
curvature  of  the  cornea  to  that  of  the  sclerotic ;  it  also  in 
all  cases  \veakens  the  accommodation,  at  first  by  pressing 
on  the  ciliary  nerves,  later  by  causing  atrophy  of  the  ciliary 
muscle ;  these  facts  together  explain  the  rapid  decrease  of 
refractive  power  (z.  e.,  rapid  onset  or  increase  of  presbyopia) 
which  is  sometimes  noticed  by  the  patient.  The  choroidal 
circulation  is  obstructed  by  the  increase  of  pressure,  and  in 
severe  glaucoma,  especially  of  old  standing,  the  anternor 
ciliary  veins  (forming  the  episcleral  plexus),  as  well  as  the 
arteries,  become  very  much  enlarged. 

Mechanism  of  Glaucoma. — The  increased  tension  is 
due  to  excess  of  fluid  in  the  eyeball.  Impeded  escape  is 
probably  the  chief  cause  of  this  excess,  and  recent  research 
has  proved  that  changes  are  present  in  nearly  all  glauco- 
matous eyes,  which  must  lessen,  or  prevent,  the  normal 
outflow.  But  increased  secretion,  and  internal  vascular 
congestion,  undoubtedly  play  an  important  part  in  certain 
cases.  Some  authorities  have  attributed  the  phenomena  of 
glaucoma  to  vaso-motor  changes  in  the  size  of  the  blood- 
vessels, but  such  hypotheses  are  wanting  in  proof.  Both 
conditions  would  have  most  effect  when  the  sclerotic  was 


GLAUCOMA 


295 


most  unyielding,  i.  e.,  in  old  age,  and  in  hypermetropic 
eyes.  It  is  probable  that  there  is  a  constant  movement  of 
fluid  from  the  vitreoushumor  through  the  suspensory  liga- 
ment of  the  lens,  and  also  from  the  anterior  part  of  the 
ciliary  processes,  into  the  anterior  chamber,  as  shown  by 
the  dotted  line  in  Fig.  99.  The  fluid  escapes  from  the  ante- 
rior chamber  into  the  lymphatics  and  perhaps  into  the  veins 

Fig.  99. 


Section  through  the  ciliary  region  in  a  health}'  human  eye.  Co.^ 
cornea;  5cL,  sclerotic;  C.  J/.,  ciliary  muscle;  (7.P. ,  two  ciliary  processes, 
one  larger  than  the  other ;  Jr.,  iris  ;  Z.,  the  marginal  part  of  the  crys- 
talline lens ;  a,  angle  of  anterior  chamber  ;  fZ,  membrane  of  Descemet, 
which  ceases  (as  such)  before  reaching  the  angle  a.  The  dotted  line 
shows  the  course  probably  taken  by  fluid  fro  n  the  anterior  part  of  the 
vitreous  into  the  posterior  aqueous  chamber,  where  it  is  augmented  by 
aqueous  humor  secreted  by  the  anterior  part  of  the  ciliary  process,  thence 
through  the  pupil  (notshown)  intotheanterior  aqueous  chamber,  to  the 
angle  a.     Suspensory  ligament  of  lens  not  shown.     X  10. 


of  the  sclerotic,  through  the  meshes  of  the  li g amentum pec- 
tinatum  (Fontana^s  spaces),  which  close  the  angle  a;  and  it 
has  been  proved  that  very  little  fluid  can  pass  through  any 
other  part  of  the  cornea.  In  glaucoma  the  angle  a  is  nearly 
always  closed,  in  recent  cases  by  contact,  in  old  cases  by 
permanent  cohesion,  between  the  periphery  of  the  iris  and 
the  cornea,  Figs.  100  and  101.     No  complete  explanation 


296 


GLAUCOMA 


of  this  advaiK-e  of  the  iris  has  yet  been  given.     Dr.  Adolf 
Weber  holds  that  the  ciliary  processes,  becoming-  swollen 


P^IG.  100. 

1. 

2^ 

Ciliary  region  from  a  case  of  acute  glaucoma  of  one  month's  duration 
(1  and  2,  situations  of  iridectomy  wounds  in  two  cases)      X  10, 

from  various  causes,  push  the  iris  forward,  and  so  start  the 
glaucomatous  state.  Priestley  Smith'  believes  that  the  pri- 
mary obstruction  is  at  the  narrow  chink  between  the  edge 
of  the  lens  and  at  the  tips  of  the  ciliary  processes  ("  circum- 
lental  spaces''),  and  that  the  block  may  depend  upon  one 

Fig.  101. 


Ciliary  region  in  chronic  glaucoma  of  three  years'  standing.     X  10. 

or  more  of  three  factors — increase  in  the  size  of  the  lens 
due  to  advancing  years, ^  abnormal  smallness  of  the  ciliary 


1  Priestley  Smith,  Trans,  of  Ophth.  Soc,  vol,  vi.,  1886. 

2  The  increase  in  the  size  of  the  lens  as  age  advances  has  been  proved 
beyond  doubt  by  Priestley  Smith's  researches.     Ibid.,  vol,  iii.  (1883). 


GLAUCOMA  297 

area  as  in  hypermetropia,  and  abnormal  enlargement  of  the 
ciliary  processes.  Obstruction  of  this  space  leads  to  rise  of 
pressure  in  the  vitreous,  followed  by  advance  of  the  lens 
and  ciliary  processes  against  the  base  of  the  iris  and  con- 
sequent closure  of  the  angle.  Brailey  holds  that  a  chronic 
inflammation  of  the  ciliary  muscle  and  processes,  and  of  the 
iris,  quickly  passing  on  to  atrophic  shrinking,  leads  to  nar- 
rowing of  the  angle  and  initial  rise  of  tension  ;^  in  a  later 
paper,  however,  he  agrees  to  some  extent  w-ith  the  view  of 
Weber,  above  referred  to.^  Cases  of  chronic  glaucoma 
have  been  seen  in  which  the  iris  w^as  congenitally  absent. 

But  there  are  cases  which  show  that  th6  matter  is  not 
always  so  simple.  Stilling,  of  Strasbourg,  has  lately  (1885) 
contended  that  the  waste  fluids  escape  by  the  central  canal 
of  the  vitreous  into  the  optic  nerve,  and  partly  also  by  fil- 
tration through  the  circum-pcipillary  portion  of  the  sclerotic, 
and  that  a  sclerosis  of  these  parts,  by  diminishing  their 
permeability,  leads  to  glaucoma  ;  Brailey^  states  from  patho- 
logical research  that  inflammation  of  the  optic  nerve  is 
always  present  quite  early  in  glaucoma,  and  that  it  precedes 
the  increased  tension  ;  and  ophthalmoscopic  examination  in 
certain  cases  lends  support  to  this  statement.*  It  may  be 
added,  in  support  of  these  views,  that  glaucoma  may  occur 
after  removal  of  the  lens,  that  in  some  cases  of  glaucoma 
the  angle  of  the  anterior  chamber  remains  freely  open,  and 
that  the  ophthalmoscopical  appearances  of  glaucoma  are 
occasionally  seen  without  increase  of  T.  (For  other  causes 
see  Secondary  Glaucoma.) 

An  over-supply  of  fluid  afi*ects  the  tension  diff*erently  in 
different  cases.  Congestion  and  ordinary  inflammations  of 
the  retina  and  uveal  tract  do  not  cause  glaucoma,  anddila- 

1  Brailey,  Ophth.  Hosp.  Reports,  x.,  pp.  14,  89,  93  (1880). 

2  Brailey,  ibid.,  p.  282  (1881). 

3  Brailey,  ibid.,  pp.  86,  277,  282. 

*  Nettleship,  St.  Thomas's  Hosp.  Rep.,  vol.  xiv. 
13* 


298  GLAUCOMA. 

tation  of  the  arteries  by  vaso-niotor  paralysis  is  said  to  be 
accompanied  by  diminished  tension.  But  tumors  in,  and 
even  upon,  the  eye  often  give  rise  to  secondary  glaucoma, 
and  probably  the  active  congestion  and  transudation  of 
fluid  and  small  cells  which  occur  near  to  a  quickly  grow- 
ing tumor  are  the  chief  factors  ;  certainly  the  glaucoma 
stands  in  no  constant  relation  either  to  the  size  or  position 
of  the  tumor.  A  relation  is  observed  in  some  cases  between 
glaucoma  and  neuralgia  of  the  fifth  nerve ;  and  T.  is  said 
to  be  lowered  in  paralysis  of  this  nerve.  Probably  the 
pain  acts  by  causing  associated  congestion,  and  thus  setting 
up  glaucoma  in  a  predisposed  eye. 

General  and  Diathetic  Causes. — In  an  eye  predis- 
posed, by  the  changes  above  mentioned  in  the  ciliary 
region,  any  cause  of  congestion  may  precipitate  an  acute 
attack.  Congestion  of  the  eyes  in  connection  with  dis- 
turbances of  the  general  circulation  from  heart  disease, 
bronchitis,  or  portal  engorgement,  or  due  to  loss  of  sleep 
from  gout,  neuralgia,  worry,  etc  ,  or  caused  by  the  over-use 
of  presbyopic  eyes  witBout  suitable  glasses,  or  by  a  blow, 
or  prolonged  ophthalmoscopic  examination,  or  exposure  to 
cold  wind,  may  all  bring  it  about.  Atropine  has  sometimes 
caused  an  attack,  because,  by  lessening  the  width,  it  in- 
creases the  thickness  of  the  iris,  and  so  crowds  it  into  the 
angle  of  the  anterior  chamber.  Iridectomy  on  one  eye 
occasionally  sets  up  acute  glaucoma  in  the  other,  probably 
by  causing  general  excitement  and  disturbance,  and  it  is 
now  customary  to  use  eserine  as  a  preventive  in  the  second 
eye  after  iridectomy  in  the  first.  Glaucoma  is  uncommon 
before  the  age  of  forty,  and  is  most  frequent  between  fifty- 
five  and  sixty-five  ;'  the  rare  cases  seen  in  young  adults  and 
children  are  generally  chronic  and  often  associated  with 

1  Statistics  of  1000  cases  collected  by  Priestley  Smith,  loc.  cit.  (1886). 
Gallenga  (Turin),  in  330 eases, finds  the  frequency  greatest  between  60 
and  70. 


GLAUCOMA.  299 

other  changes  in  the  eyes,  particularly  myopia.  Acute 
cases  are  often  dated  from  a  period  of  overwork  of  the  eyes, 
or  want  of  sleep,  as  from  sitting  up,  nursing,  etc.  Patients 
who  have  had  glaucoma  in  one  eye  should  be  emphatically 
warned  as  to  the  danger  of  over-using  the  e\^es,  or  of  work- 
ing without  proper  glasses,  and  against  dietetic  errors. 
Primary  glaucoma  is,  according  to  the  newest  statistics,^  as 
a  whole,  rather  commoner  in  women  than  men  ;  and  whilst 
the  acute  congestive  forms  are  much  commoner  in  women, 
very  chronic  glaucoma  is  rather  commoner  in  men. 

Treatment. — Iridectomy,  or  an  equivalent  operation, 
is,  with  very  few  exceptions,  the  only  curative  treatment. 
Eserine  or  pilocarpine  (gr.  ^-i]  to  §j)  used  locally,  how- 
ever, diminishes  the  tension  in  acute  glaucoma,  and  a  few 
attacks  seem  to  have  been  permanently  cured  by  it.  But 
although  seldom  really  curative,  eserine  is  of  great  tempo- 
rary value  in  cases  where  an  operation  has  to  be  deferred. 
It  has  little  or  no  effect  on  the  tension  unless  it  causes 
marked  contraction  of  the  pupil.  Eserine  acts  (1)  by 
stretching  the  iris  and  drawing  it  away  from  the  angle 
of  the  anterior  chamber;  (2)  by  the  contraction  of  the 
ciliary  muscle  which  it  causes,  the  meshes  of  the  tissue 
bounding  this  angle  are  more  widely  opened.  Eserine 
causes  congestion  of  the  ciliary  processes,  and  probably 
this  explains  why,  if  it  do  not  soon  relieve,  it  sometimes 
aggravates,  the  symptoms.  It  is  of  use  chiefly  in  recent, 
and  especially  in  acute,  cases ;  a  solution  of  half  a  grain 
or  a  grain  of  the  sulphate  to  the  ounce  is  to  be  used  about 
every  two  hours  and  continued  if  relief  be  obtained.  If 
in  a  few  hours  it  increases  the  pain  and  do  not  lessen  the  T. 
it  should  be  abandoned.  The  pain  in  acute  cases  may  be 
much  relieved  by  leeching,  warmth  to  the  eye,  derivative 

1  Priestley  Smith,  loc.  cit.  (1886);  in  1000  cases  569  women  and  431 
men. 


800  GLAUCOMA. 

treatment  such  as  purgation  and  hot  foot-baths,  and  sopo- 
rifics. Cocaine  is  used  with  the  eserine  by  some  surgeons, 
and  seems  to  increase  its  efficacy. 

Iridectomy  cures  glaucoma  by  permanently  reducing  the 
tension  to  the  normal  or  nearly  normal  degree.  It  is  found 
that  the  best  results  are  obtained — (1)  if  the  path  of  the 
incision  lie  in  the  sclerotic  from  1  to  2  mm.  from  the  ap- 
parent corneal  border,  Fig.  100 ;  (2)  if  the  wound  be  large, 
allowing  removal  of  about  a  fifth  of  the  iris;  (3)  if  the  iris 
be  removed  quite  up  to  its  ciliary  attachment,  which  is  best 
done  by  first  cutting  one  end  of  the  drawn-out  loop  of  iris, 
then  tearing  it  from  its  ciliary  attachment  along  the  whole 
extent  of  the  wound,  and  cutting  through  the  other  end 
separately.  (See  Operations. )  Evacuation  of  the  aqueous 
humor  by  paracentesis  of  the  anterior  chamber  gives  only 
temporary  relief. 

A  mere  wound  in  the  sclerotic,  differing  but  little  in  posi- 
tion and  extent  from  that  made  for  iridectomy,  is  sufficient 
to  relieve  +  T.,  and  to  cure  some  cases  of  glaucoma  per- 
manently, and  this  operation,  subcovjunctival  sclerotomy^ 
was  largely  adopted  by  some  operators  a  few^  years  ago. 
Iridectomy,  however,  has  held  its  ground  as  the  more 
effectual  operation.  Sclerotomy  is  open  to  objection — ( I) 
because  the  position  and  length  of  the  wound  are  not  per- 
fectly under  control;  if  too  far  forward  and  too  short  it 
is  ineffectual,  if  too  far  back  and  too  long  there  is  risk  of 
wounding  the  ciliary  processes  and  getting  hemorrhage 
into  the  vitreous;  even  shrinking  of  the  operated  eye  and 
sympathetic  inflammation  of  the  other  have  occurred;  (2) 
because  the  iris  may  prolapse  into  the  wound,  and  need 
removal,  and  the  operation  then  becomes  an  iridectomy  ; 
(3)  when  the  anterior  chamber  is  very  shallow  sclerotomy 
cannot  be  supposed  to  aid  the  exit  of  fluid  so  much  as  the 
removal  of  a  piece  of  the  iris. 

Several  other  operations,  the  principle  of  which  is  to 


GLAUCOMA.  301 

make  a  puncture  at  the  sclero-corneal  junction,  or  through 
the  .sclerotic  near  the  equator,  have  been  tried,  but  have 
not  .^-ained  general  confidence. 

Whichever  operation  be  eraplo^'ed  in  glaucoma,  the  for- 
mation of  the  operation  scar  in  the  sclerotic  is  certainly  a 
most  important  factor. 

Iridectomy  in  acute  glaucoma  no  doubt  acts,  at  first,  by 
removing  a  portion  of  the  iris  from  the  blocked  angle,  Fig. 
100,  and  thus  allowing  the  normal  escape  of  fluid.  Some 
high  authorities,  hold,  however,  that  its  permanent  effect  is 
due  to  the  formation,  at  the  seat  of  the  wound,  of  a  layer 
of  tissue  more  pervious  to  the  eye-fluids  than  the  sclerotic, 
*'  filtration-scar  ;"  an  iridectomy  for  glaucoma  which  heals 
slowly  is  at  any  rate  believed  to  be  more  favorable  than  one 
which  heals  immediately,  i.  e.,  with  no  new  tissue,  and  a 
slight  bulging  of  the  scar  is  held  by  some  surgeons  to  be 
rather  desirable  than  otherwise.  That  a  mere  sclerotomy 
may  be  sufiBeient  points  in  the  same  direction.  Such  a 
porous  scar  never  forms  if  the  incision  be  in  the  cornea. 

An  operation,  usually  iridectomy,  is  to  be  done  in  all 
cases  of  acute  and  subacute  glaucoma,  whether  there  be 
great  pain  or  not,  so  long  as  some  sight  still  remains,  and 
even  if  all  p.  1.  be  lost,  provided  that  the  blindness  be  of 
only  a  few  days'  duration.  Even  if  the  eye  be  permanently 
quite  blind,  iridectomy  or  sclerotomy,  or  perhaps  stretch- 
ing the  infra-trochlear  nerve  is  sometimes  preferable  to 
excision  of  the  globe,  for  the  relief  of  pain. 

Chronic  C' simple")  glaucoma  should,  in  my  opinion, 
always,  if  possible,  be  operated  upon  early,  as  soon  as  the 
diagnosis  is  certain  and  before  the  field  is  much  damaged ; 
the  prognosis  is  then  fairly  good.  In  advanced  chronic 
glaucoma,  when  the  field  has  become  much  contracted, 
visual  acuteness  usually  much  lowered,  and  the  disc  pale 
and  considerably  cupped,  the  rule  is  less  clear,  for  it  is  well 
known  that  the  effect  of  operation  in  such  cases  is  far  from 


302  GLAUCOMA. 

constant.  But  as  no  other  treatment  is  of  use,  and  iri- 
dectomy is  certainly  often  beneficial,  it  should  usually  be 
performed,  especially  if  the  disease  aflfect  both  eyes.  The 
patient's  prospect  of  life  must  be  allowed  for  in  chronic 
glaucoma  ;  if  he  be  old  and  feeble,  life  may  end  before  the 
disease  have  progressed  to  blindness. 

'I'here  is  often  difficulty  in  deciding  upon  the  best  course 
in  the  so-called  "premonitory"  stage,  which  consists,  in 
truth,  of  transient  attacks  of  slight  glaucoma.  When  it  is 
clear  that  attacks  of  temporary  mistiness  and  rainbows 
are  glaucomatous,  and  that  they  are  getting  more  frequent, 
iridectomy  should  seldom  be  deferred ;  but  if  the  patient 
can  be  seen  at  short  intervals,  eserine  should  have  a  fair 
trial  before  operation  is  resorted  to.  It  is  to  be  remembered 
that  iridectomy  done  w^hen  sight  is  still  good  may,  by  al- 
lowing spherical  aberration  and  causing  corneal. astigma- 
tism, increase  the  defect;  and  this,  though  not  of  neces- 
sity a  contra-indication,  must  be  taken  into  account. 

The  Prognosis  after  operation  is,  in  general  terms, 
better  in  proportion  as  the  disease  is  acute  and  recent.  If 
operated  on  within  a  few  days  of  the  onset  of  acute  symp- 
toms, provided  that  fingers  can  still  be  counted  at  the  time 
of  operation,  sight  is  often  restored  to  the  state  in  which  it 
was  at  the  onset,  i.  e.,  if  the  disease  be  recent,  nearlv  per- 
fect sight  will  be  restored.  Even  in  cases  combining  the 
maximum  of  acuteness  and  severity,  in  which  vision  has 
for  the  last  few  days  been  reduced  to  mere  p.  1.,  the  opera- 
tion is  often  successful  in  restoring  some  degree  of  useful 
sight.  But  the  prognosis  is  not  always  so  favorable  in 
acute  glaucoma,  especially  if  the  patient's  health  be  much 
broken  down  ;  and  if  there  be,  as  is  by  no  means  uncom- 
mon, evidence  that  sight  had  been  already  damaged  by 
chronic  glaucoma  before  the  acute  attack  set  in,  the  prog- 
nosis must  be  guarded.     In  simple  chronic  glaucoma  we 


GLAUCOMA  303 

can  only  hope,  as  a  rule,  to  stop  the  disease  where  it  is  and 
prevent  the  sight  from  getting-  worse. 

The  full  effect  of  the  operation  is  not  seen  for  several 
weeks,  though  a  marked  immediate  effect  is  produced  in 
acute  cases.  In  cases  of  long  standing  T.  may  remain 
permanently  rather  -}-  after  operation,  without  bad  effect, 
provided  it  be  very  much  less  than  before  the  operation ; 
the  eye  tissues  can  in  some  degree  adapt  themselves  to 
increased  pressure. 

A  second  iridectomy  in  the  opposite  direction,  or  a 
sclerotomy,  should  be  done  if  T.,  having  been  reduced  to 
normal,  or  very  slightly  -|-,  after  the  first  operation,  rise 
definitely  and  be  accompanied  by  a  return  of  other  symp- 
toms ;  but  several  weeks  should  generally  elapse,  for  slight 
waves  of  glaucomatous  tension  may  occur  before  the  eye 
has  fully  recovered  from  the  first  operation,  and  these  may 
often  be  relieved  by  other  means.  Cases  which  relapse 
definitely,  or  which  steadily  get  worse  after  the  first  oper- 
ation, are  always  very  grave,  and  the  second  operation  must 
not  be  confidently  expected  to  succeed.  If,  after  iridec- 
tomy in  acute  glaucoma,  the  symptoms  are  not  relieved, 
even  for  a  time,  or  become  worse,  some  complication  is 
to  be  suspected,  such  as  hemorrhage  from  the  retina  or 
choroid,  or  a  tumor.     (See  Secondary  Glaucoma.) 

Other  Treatment. — If  we  are  obliged  to  delay  the 
operation,  the  other  means  mentioned  at  p.  299  should  be 
prescribed,  including  eserine.  The  diet  should,  as  a  rule, 
be  liberal,  unless  the  patient  be  plethoric.  It  is  very  im- 
portant to  insure  sound  sleep  and  mental  calm.  After  the 
operation,  until  the  eye  has  become  quiet,  all  causes  likely 
to  induce  congestion  must  be  carefully  avoided,  such  as 
use  of  the  eyes,  stooping  or  straining,  and  prolonged  oph- 
thalmoscopic examination.  Atropine  must  never  be  used. 
We  should  be  on  the  alert  for  the  earliest  symptoms  in  the 


304  GLAUCOMA. 

second  eye  after  operation  on  the  first,  and  the   use   of 
eserine  may  be  advisable  as  a  prophylactic. 

In  a  few  cases  of  very  chronic  or  subacute  character, 
with  great  increase  of  T.,  iridectomy  seems  to  aggravate 
the  disease,  being  followed,  not  even  by  temporary  benefit, 
but  by  persistence  of -|-  T.,  increased  irritability,  and  still 
further  deterioration  of  sight  {''glaucoma  malignum^^). 
Perhaps  the  tilting  forward  of  the  lens,  which  sometimes 
follows  iridectomy,  may  account  for  the  result. 

Glaucoma  may  occur  independently  in  cataractous  eyes, 
and  in  eyes  from  which  the  lens  has  been  extracted,  with 
or  without  iridectomy. 

Secondary  gclaucoma  may  be  acute  or  chronic,  accord- 
ing as  it  is  a  consequence  of  active  disease  or  of  sequelae. 
It  may  be  caused  by  circular  iritic  synechia  with  bulging 
of  the  iris.  Various  forms  of  chronic  irido-keratitis  and 
irido-choroiditis,  especially  in  the  sympathetic  form,  are 
liable  to  be  accompanied  by  it;  in  the  former  it  may  be 
due  to  choking  of  the  spaces  of  Fontana  l)y  inflammatory 
products,  and  perhaps  to  excessive  secretion  from  the 
ciliary  processes;  in  the  sympathetic  disease,  to  total  pos- 
terior synechia.  It  may  follow  perforation  of  the  cornea 
with  large  anterior  synechia.  The  eye  often  becomes  tem- 
porarily glaucomatous  in  the  course  of  traumatic  cataract 
from  the  pressure  of  the  swollen  lens  on  the  iris  and  ciliary 
processes,  especially  in  patients  past  middle  life.  In  none 
of  these  cases  is  there  much  danger  of  mistaking  secondary 
for  idiopathic  glaucoma. 

But  secondary  glaucoma  may  result  from  various  deeper 
changes.  When  the  lens  is  dislocated,  either  behind  or  in 
front  of  the  iris,  it  often  sets  up  glaucoma,  sometimes  of 
very  severe  type,  apparently  by  pressing  on  the  ciliary  pro- 
cesses or  iris.  There  is  generally  the  history  of  a  blow ; 
and  in  posterior  dislocation,  even  if  the  edge  of  the  dis- 
placed lens  cannot  be  seen,  the  iris  is  usually  tremulous, 


GLAUCOMA.  305 

and  its  surface  concave  or  flat  at  one  part,  whilst  bulging 
or  prominent  at  another.  If  we  are  sure  that  a  lens  dislo- 
cated into  the  vitreous  is  causing  the  symptoms,  it  should 
be  extracted  with  a  scoop  (see  Operations),  and  if  lying  in 
the  anterior  chamber  should  also  usually  be  removed.  If 
the  eye  become  glaucomatous  immediately  after  a  severe 
blow  the  condition  of  the  lens  may  not  be  ascertainable, 
and  then  an  iridectomy  must  be  done  and  the  eye  be 
Matched  ;  vitreous  is  very  likely  to  escape  at  the  operation 
if  there  be  dislocation  of  the  lens,  for  the  latter  condition 
implies  rupture  of  the  suspensory  ligament.  Hemorrhage 
into  an  eye  whose  retina  is  detached,  e.  g.,  in  high  degrees 
of  myopia,  may  give  rise  to  acute  glaucoma  with  severe 
pain.  A  glaucomatous  attack  generally  occurs  during  the 
growth  of  an  intra-ocular  tumor.  It  is  often  impossible  to 
distinguish  such  a  case,  in  an  adult,  from  one  of  idiopathic 
glaucoma  of  the  same  severity  and  standing ;  for  even  if 
the  lens  be  not  opaque,  and  it  often  is  so,  the  other  media 
will  probably  be  too  hazy  to  allow  an  ophthalmoscopic 
examination,  the  growth  itself  is  usually  of  a  dark  color, 
and  both  idiopathic  glaucoma  and  choroidal  sarcoma  are 
diseases  of  advanced  life.  In  almost  every  case,  however, 
the  glaucoma  will  be  "absolute,"'  and  will  be  known  to 
have  been  so  for  weeks  or  months,  and  there  will  also  be 
the  negative  fact  that  the  fellow-eye  shows  no  signs  of 
glaucoma.  If  a  glaucomatous  eye,  which  has  been  abso- 
lutely blind  for  several  months,  remain  painful  and  con- 
gested, and  its  media  too  opaque  for  ophthalmoscopic 
examination,  it  should  be  excised  as  likely  to  contain  a 
tumor.  Tumors  in  the'eyes  of  children  also  cause  secondary 
glaucoma,  but  there  is  seldom  any  difficulty  in  making  the 
diagnosis  ;  the  patient  is  far  below  the  age  for  primary 
glaucoma,  and  the  growth  is  usually  conspicuous  from  its 
whitish  color.  Secondary  glaucoma  now  and  then  super- 
venes in  cases  of  albuminuric  retinitis,  and  of  embolism  or 


306  GLAUCOMA. 

thrombosis  of  the  retinal  vessels,  and  in  eases  of  retinal 
hemorrhage  from  other  causes,  hemorrhagic  glaucoma.  In 
glaucoma  with  hemorrhage  the  diagnosis  can  sometimes  be 
completed  only  after  an  unsuccessful  operation  has  shown 
that  the  case  is  not  a  simple  one. 


CHAPTER    XYIII. 

TUMORS    AND    NEW-GROWTHS    OF    THE    EYEBALL    AND 
CONJUNCTIVA. 

A.     Tumors   and   Groayths   of   the   Conjunctiva   and 
Front  of  the  Eyeball. 

Cauliflower  warts,  with  narrow  pedicles  like  those  on 
the  glans  penis,  but  flattened  like  a  cock's  comb  by  pres- 
sure, are  sometimes  seen  on  the  ocular  and  palpebral  con- 
junctiYa.  Each  wart,  with  a  small  portion  of  healthy  con- 
junctiYa  around  its  pedicle,  must  be  snipped  off,  or  the 
growth  is  likely  to  recur. 

Lupus  occasionally  extends  from  the  skin  of  the  eyelid 
to  the  palpebral,  and  later  to  the  ocular,  conjunctiYa.  The 
part  affected  is  Yery  vascular,  irregularly  thickened,  and 
ulcerated.  It  may  also  appear  independently  on  the  pal- 
pebral conjunctiYa,  the  skin  of  the  eyelid  being  healthy. 
It  is  usually  limited  to  a  part  of  one  eyelid.  There  may 
be  co-existent  lupus,  either  of  skin  or  oral  mucous  mem- 
brane. There  seems  much  doubt  whether  any  distinction 
can  be  made  between  the  rare  cases  that  haYe  been  de- 
scribed as  tubercle  of  the  co??J«7?c^u"a  (ocular  or  palpebral), 
and  what  most  surgeons  call  lupus.^  Conjunctival  lupus 
is  much  benefited  by  the  usual  local  treatment. 

The  eyelid,  and  especially  the  tarsus,  is  now  and  then 
the  seat  of  diffused  gummatous  inflammation  in  the  tertiary 

1  Consult  Hirschberg,  Trans.  Internat.  Med.  Cong.  1881,  3,  117; 
Benson,  Trans.  Oph.  Soc,  y.  41  and  51  (1885)  ;  Mules,  Oph.  Rev.,  iv.  3 
(1885). 


308  NEW -GROWTHS     OF     CONJUNCTIVA. 

stage  of  syphilis.  The  infiltration  gives  rise  to  a  hard,  in- 
dolent swelling  of  the  whole  lid,  syjihililictardtis.  Chancres 
and  tertiary  syphilitic  ulcers  may  occur  on  the  lids. 

Pinguecula,  a  yellowish  spot,  looking  like  adipose  tissue, 
in  the  conjunctiva  close  to  the  inner  or  outer  edge  of  the 
cornea,  consists  of  thickened  conjunctiva  and  subconjunc- 
tival tissue,  and  contains  no  fat.  It  is  commonest  in  old 
people,  and  in  those  whose  eyes  are  exposed  to  local  irri- 
tants. Though  of  no  consequence,  advice  is  often  asked 
about  it. 

Pterygium  is  a  triangular  patch  of  thickened  ocular 
conjunctiva,  the  apex  of  which  encroaches  on  the  cornea  ; 
it  is  almost  always  seated  on  the  exposed  part  of  the 
eye.  It  varies  much  in  area,  thickness,  and  vascularity, 
and,  though  usually  stationary,  may  be  progressive.  It  is 
to  be  distinguished  from  opacit}^  of  the  cornea  and  from  the 
cicatricial  band,  symblepharon,  which  often  forms  between 
lid  and  globe  after  burns  or  wounds  of  the  conjunctiva. 
It  is  rarely  seen  except  in  those  who  have  spent  some  years 
in  hot  countries.  The  best  treatment  is,  after  dissecting  up 
the  growth,  to  double  it  inward  upon  itself,  drawing  its 
apex  into  the  chink  betw^een  sclerotic  and  conjunctiva  by 
means  of  a  deep  suture,  which  is  brought  out  again  near 
the  caruncle ;  or  to  transplant  the  growth  into  a  cleft  in 
the  conjunctiva  below^  the  cornea ;  excision  or  ligature  is 
less  effectual.  Adhesion  of  swollen  conjunctiva  to  a  mar- 
ginal ulcer  of  cornea  is  the  starting-point  of  pterygium. 

Small  thin  cysts,  sometimes  elongated  and  beaded,  with 
clear  watery  contents,  are  not  uncommon  in  the  ocular  con- 
junctiva near  to  one  of  the  canthi.  They  are  formed  by 
distention  of  valved  lymphatic  trunks. 

Dermoid  tumors  (solid)  of  the  eyeball  are  much  scarcer 
than  the  cystic  dermoids  of  the  eyebrow.  They  are  w^hitish, 
smooth,  hemispherical,  and  firm.  They  generally  lie  in 
the  palpebral  fissure,  and  are  either  wholly  conjunctival 


TUMORS    OF     CONJUNCTIVA.  309 

and  movable,  or  partly  corneal  and  fixed.  They  are  solid, 
and  hairs  may  grow  from  their  surface.  They  may  be 
combined  with  other  congenital  anomalies  of  the  eye  or 
lids.  The  corneal  portion  of  such  a  tumor  cannot  always 
be  perfectly  removed. 

The  swelling  in  some  cases  of  episcleritis,  syphilitic  or 
not,  may  be  mistaken  for  a  tumor.  A  few  cases  of  inno- 
cent tumor  on  the  edge  of  the  cornea  have  been  described 
as  fibroma;  it  is  not  certain  that  some  of  these  may  not 
have  been  chronic  gummata. 

A  congenital  fibro-fatty  growth  sometimes  occurs  in  the 
form  of  a  yellowish,  lobulated,  tongue-like  protrusion  be- 
tween the  lid  and  the  globe,  and  usually  at  the  outer  and 
upper  side  of  the  orbit. 

Cystic  tumors  may  be  met  with  beneath  the  palpebral 
conjunctiva.  The  very  rare  form  known  as  Dacryops  is  a 
bluish  tumor  caused  by  occlusion  and  distention  of  a  duct  of 
the  lachrymal  gland  ;  but  other  cystic  conjunctival  tumors 
are  met  with  which  cannot  be  so  explained.  Fibrous,  and 
even  bony,  tumors  are  occasionally  seen  in  the  substance  of 
the  upper  lid,  perhaps  starting  from  the  tarsus ;  in  one 
case  a  tooth  was  removed  from  the  lower  lid  by  Carver 
(Xagel,  p.  423) ;  and  soft  polypoid  growths  have  been  met 
with  in  the  sulcus  between  lid  and  globe. 

Malignant  tumors  arise  much  less  commonly  on  the 
front  of  the  eye  than  in  the  choroid  or  retina.  They  may 
be  either  epithelial  or  sarcomatous.  An  injury  is  often 
stated  to  be  the  cause  of  the  growth. 

Epithelioma  may  begin  on  the  ocular  conjunctiva,  in 
which  case  it  remains  movable,  or  at  the  sclero-corneal 
junction,  when  it  quickly  encroaches  on  the  cornea,  infil- 
trates its  superficial  layers,  and  becomes  fixed.  It  may  be 
pigmented.  When  such  a  growth  is  not  seen  until  late  it 
may  perhaps  be  as  large  as  a  walnut,  may  cover  or  sur- 


310  NEW-GROWTHS     OF    CONJUNCTIVA. 

round  the  cornea  and  present  a  papillary  or  lobulated 
surface.     The  glands  in  front  of  the  ear  may  be  enlarged. 

Sarcoma  in  this  region  may  or  may  not  be  pigmented. 
It  generally  arises  at  the  sclero-corneal  junction,  and  when 
small  the  conjunctiva  is  traceable  over  the  growth.  But 
in  advanced  cases  it  may  be  impossible  from  the  clinical 
features  to  diagnose  the  nature  of  a  tumor  in  this  part. 

Movable  tumors,  epithelioma,  not  involving  the  cornea, 
may  be  cut  off,  but  are  very  likely  to  recur ;  and  recur- 
rence is  still  more  likely  in  the  case  of  growths  fixed  to 
the  cornea  or  sclerotic.  Removal  of  the  eyeball  at  an 
earh^  date,  especially  in  the  case  of  sarcomata,  is  the  best 
course  in  the  majority  of  cases. 

The  lachrymal  sac  is  occasionally  the  seat  of  new-growth, 
which  may  be  mistaken  for  chronic  mucocele. 

B.  Intra-ocular  Tumors. 

By  far  the  commonest  forms  are  glioma  of  the  retina 
and  sarcoma  of  the  choroid. 

Glioma  of  the  retina  is  a  disease  of  infancy  or  early 
childhood,  the  patients  being  generally  under  three  years 
old  when  first  brought  for  treatment ;  it  may,  however,  be 
present  at  birth,  and  is  said  occasionally  to  begin  as  late 
as  the  eleventh  or  twelfth  year.  Glioma  is  very  soft,  com- 
posed of  small  round  cells  which  grow  from  the  granule 
layers  of  the  retina,  and  it  either  grows  outward,  causing 
detachment  of  the  retina,  or  inward  into  the  vitreous; 
often  several  more  or  less  separate  lobules  are  present.  It 
often  fills  the  eyeball  in  a  few  months  and  then  spreads  by 
contact  to  the  choroid,  and  to  the  sclerotic  and  orbit.  It 
is  especially  prone  to  travel  back  along  the  optic  nerve 
to  the  brain  ;  and  it  may  cause  secondary  deposits  in  the 
brain  and  in  the  scalp,  and  more  rarely  in  distant  parts. 
If  the  eye  be  removed  before  either  the  optic  nerve  or  the 


INTRA-OCULAR    TUMORS.  311 

orbital  tissues  are  infiltrated  the  cure  is  radical,  but  in  the 
more  numerous  cases,  where  the  patient  is  not  seen  till 
what  may  be  called  clinically  the  second  stage  (see  below), 
a  fatal  return  in  the  orbit  or  within  the  skull  is  the  rule. 
Glioma  sometimes  occurs  in  both  eyes  and  in  several  chil- 
dren of  the  same  parents. 

The  earliest  symptom  is  a  shining  whitish  appearance 
deep  in  the  eye,  and  the  eye  is  soon  noticed  to  be  blind;  as 
there  is  neither  pain  nor  redness,  advice  is  seldom  sought 
at  this  stage.  T.  is  n.  or  rather  — .  When  the  peculiar 
appearance  has  become  very  striking,  or  the  eye  becomes 
painful,  the  child  is  brought.  In  this  (the  second)  stage 
there  is  generally  some  congestion  of  the  scleral  vessels, 
and  a  white,  pink,  or  yellowish  reflection  from  behind  the 
lens  (which  remains  clear),  steaminess  of  the  cornea,  mydri- 
asis,T.  -f,  anterior  chamber  shallow  and  of  uniform  depth  ; 
there  may  be  enlargement  or  prominence  of  the  eyeball. 
On  examination  by  focal  light,  some  vessels  can  generally 
be  seen  on  the  whitish  background,  and  white  specks,  indi- 
cating degeneration,  are  sometimes  present. 

In  young  children  the  above  appearances  are  sometimes 
simulated  by  inflammatory  changes  in  the  vitreous,  with 
detachment  ofthe  retina, the  result  of  spontaneously  arrested 
severe  irido-choroiditis.  The  differential  diagnosis  is  occa- 
sionally very  difficult.  In  these  cases  of  j^seudo -glioma  iritic 
adhesions  are  usually  present,  T.  is — ,  the  eye  somewhat 
shrunken,  the  anterior  chamber  deep  at  its  periphery,  whilst 
absent  or  shallow  at  the  centre.  There  is  often  the  history 
of  some  illness  with  a  definite  inflammation  of  the  eye  be- 
fore the  change  was  seen  in  the  pupil.  When  in  doubt  the 
eye  should  be  excised,  for  there  is  reason  to  think  that  ex- 
ceptionally a  true  glioma  may  inflame  and  shrivel  for  a 
time,  and  the  nature  of  the  case  be  thus  obscured  until  too 
late,^  when  grow^th  has  again  set  in. 

*  See  two  cases  in  point  by  Snell  and  Brailey,  Trans.  Oph.  Soc,  iv. 
i9^,et  »eq.  (1884). 


312  NEW-GROWTHS     OF     CONJUNCTIVA. 

Sarcoma  of  the  choroid  and  ciliary  body  is  a  growth  of 
late  01*  middle  life,  being- rarely  seen  below  the  age  of  thirty- 
five.     The  majority  of  these  tumors  are  pigmented,  melan- 
otic, some  being  quite  black,  others  mottled  or  streaked. 
A  few  are  free  from  pigment.     Some  are  spindle-celled  or 
mixed,  others  composed  of  round  cells  ;  some  are  truly  alve- 
olar, but  in  many  specimens  there  is  very  little  connective- 
tissue  stroma,  and  no  very  defined  arrangement  of  the  cells. 
These  tumors  are  moderately  firm  but  friable  ;  some  are 
very    vascular,  and  hemorrhages  often  occur  into  them. 
The  tumor  grows  from  a  broad  base,  and  usually  forms  a 
w^ell-defined  rounded  prominence,  pushing  the  retina  before 
it ;  blood  or  serous  fluid  is  effused  round  its  base,  so  that 
the  retinal  detachment  is  more  extensive  than  the  tumor. 
These  tumors  often  grow  slowly  so  long  as  they  are  wholly 
contained  within  the  eye,  and  several  years  may  elapse  be- 
fore the  growth  passes  out  of  the  eye  and  invades  the  orbit. 
Orbital  infection  does  not  usually  occur  till  the  globe  is 
filled  to  distention  by  the  growth  ;  but  it  may  happen  much 
earlier,  the  cells  travelling  out  along  the  sheaths  of  the 
perforating  bloodvessels  and  producing  large  extra-ocular 
growths,  while  the  primar}^  intra-ocular  tumor  is  still  quite 
small.     The  lymphatic  glands  do  not  enlarge,  but  there  is 
great  danger  of  secondary  growths  in  distant  parts,  espe- 
cially in  the  liver,  a  risk  not  entirely  absent  even  when  the 
eye  tumor  is  small.     Hence  early  removal  of  the  globe  is 
of  the  utmost  importance,  and  a  good,  though  not  too  con- 
fident, prognosis  may  be  given  when  the  optic  nerve  and 
tissues  of  the  orbit  show  no  signs  of  disease. 

Metastatic  growths. — In  nearly  every  case  malignant 
tumor  of  the  choroid  is  primary,  but  it  is  important  to 
know  that  growths  may  occur  here  secondary  to  those  in 
other  parts  of  the  body  ;  in  one  case,  quoted  by  Manz,  both 
eyes  were  affected,  the  original  growth  being  cancer  of  the 
breast. 


INTRA -OCULAR  TUMORS.  313 

Symptoms  and    Course. — If  the   case  be  seen   early, 
when  defect  of  sight  is  the  only  symptom,  the  tumor  can 
often  be  seen  and  recognized  by  its  well-defined  rounded 
outline,  some  folds  of  detached  retina  often  being  visible 
near  it;  the  pupil,  cornea,  and  tension  will  probably  be 
natural.     When  the  tumor  originates  in  the  central  region 
the  sight  is  immediately  affected,  and  the  patient  seeks  ad- 
vice very  early  ;  the  differential  diagnosis  then  lies  between 
localized  plastic  choroiditis  and  tumor.     In  tumor  there  is 
often  some  detachment  of  the  retina  at  or  near  the  area  of 
the  disease,  but  there  is  no  evidence  of  retinitis,  and  no 
patches  of  black  pigment  about  the  swelling.     By  ophthal- 
moscopic estimation  the  diseased  area  is  found  to  be  more 
or  less  raised.     An  inflammatory  exudation  of  similar  size 
commonly  causes  haze  of  the  neighboring  retina,  and  opaci- 
ties in  the  vitreous  ;  if  of  some  weeks'  duration,  part  of  it 
will  usually  have  become  absorbed,  leaving  exposed  scle- 
rotic with  accumulations  of  pigment.     But  sooner  or  later 
the  tumor  in  its  growth  sets  up  symptoms  of  acute  or  sub- 
acute glaucoma,  sometimes  iritis ;  subsequently  secondary 
cataract  forms.     It  is  in  this  glaucomatous  (second)  stage 
that  relief  is  usually  sought.     Unless  some  part  of  the 
tumor  happens  to  be  visible  outside  the  sclerotic,  or  project 
into  the  anterior  chamber,  a  positive  diagnosis  will  often 
now  be  impossible,  owing  to  the  opacity  of  the  media; 
although  by  exclusion  we  may  often  arrive  at  great  proba- 
bility.    If  the  eye  be  left  alone,  or  iridectomy  be  performed, 
glaucomatous  attacks  and  pain  will  recur,  and  the  eye  will 
enlarge  and  gradually  be  disorganized  by  the  increasing 
growth,  which  will  then  quickly  fill  the  orbit  and  fungate. 
But  sometimes  a  deceptive  period  of  quiet  follows  the  glau- 
comatous attack ;  even  decided  shrinking  and  softening  of 
the  eye  may  occur  ;  but  the  growth  will  sooner  or  later 
make  a  fresh  start  and  become  apparent.     It  is  chiefly  in 
very  old  patients  that  this  slow  course  is  noticed.    Sarcoma 

14 


814  NEW-GROWTHS    OF    CONJUNCTIVA. 

is  especially  likely  to  form  in  eyes  previously  injured,  or 
already  shrunken  from  disease. 

Thus  it  is  apparent  that  in  a  majority  of  cases  of  cho- 
roidal tumor  we  can  only  guess  at  the  truth.  We  suspect 
a  tumor  andurge  excision  in  the  following  cases:  (1)  When 
an  eye  that  has  been  for  some  time  failing  or  blind  from 
deep-seated  disease  becomes  painful,  congested,  and  glauco- 
matous, there  being  no  glaucoma  of  the  other  eye,  and  par- 
ticularly if  there  be  secondary  cataract.  (2)  Similar  eyes 
with  normal  or  diminished  tension  are  best  excised  as  pos- 
sibly containing  tumor.  (3)  In  extensive  detachment  of 
retina  confined  to  one  eye,  without  history  of  injury  or  evi- 
dence of  myopia,  the  patient  should  be  warned,  or  the  eye 
excised,  according  to  circumstances. 

In  all  cases  of  suspected  glioma  or  sarcoma  the  eye  should 
be  opened  at  once,  and,  if  a  tumor  be  found,  the  cut  end  of 
the  optic  nerve  of  the  excised  eye  should  be  carefully 
looked  at ;  if  this  be  pigmented  or  thickened,  another 
piece  should  be  at  once  removed,  and  the  orbit  searched 
by  the  finger  for  evidence  of  growth  ;  the  surface  of  the 
eye  should  also  be  carefully  examined  for  external  growths. 
When  infection  of  the  nerve  or  orbit  is  suspected  the  orbit 
should  be  cleared  out  and  chloride  of  zinc  paste  applied. 

Tumors  of  the  iris  are  rare.  Melanotic  as  well  as  un- 
pigmented  sarcomata  are  occasionally  met  wnth.^  The 
definite  development  of  melano-sarcoma  of  the  iris  has 
been  known  to  be  preceded  for  many  years  by  an  appa- 
rently innocent  pigmented  spot  on  the  iris.  In  eyes  blind 
and  degenerated  after  irido-cyclitis,  the  uveal  pigment  may 
increase  in  amount,  and  creep  round  the  pupillary  border 
to  the  anterior  surface  of  the  iris;  these  areas  of  new  pig- 
ment might  be  mistaken  for  melanotic  growths.    Sebaceous 

1  A  well  reported  case,  with  numerous  references,  is  given  by  Little, 
in  Trans.  Ophth.  Soc,  vol.  iii.,  1883. 


INTRA-OCULAR     TUMORS.  315 

or  epithelial  tumors  are  also  seen  ;  they  are  nearly  always 
the  result  of  transplantation  of  epithelium,  or  of  a  hair, 
into  the  iris  through  a  perforating  wound  of  the  cornea. 
In  rare  cases  cystic  tumors  with  thin  walls  are  formed  be- 
tween the  layers,  or  connected  with  the  posterior  surface  of 
the  iris,  particularly  in  eyes  which  have  been  operated  on 
or  otherwise  injured. 

Diffuse  sarcoma  of  iris. — Sarcoma  of  the  iris  may  be 
white  or  pigmented ;  it  usually  takes  the  form  of  a  single 
large  prominent  growth.  A  melanotic  tumor  of  the  iris 
has  been  seen  to  develop  from  what  appeared  to  be  a  natu- 
ral pigment  spot.  I  have  twice  seen  a  sarcoma  of  the  iris 
take  the  form  of  a  diffused  thickening,  with  a  mottled  or 
tortoise-shell  aspect ;  such  a  diffuse  form  is  more  difficult  to 
diagnose,  and  probably  more  dangerous,  if  left  alone,  than 
a  definite  tumor. 

Cases  of  disease  of  the  iris  are  seen  from  time  to  time, 
the  special  feature  of  which  is  the  presence  of  one  or  more 
nodular  growths,  usually  of  small  size ;  iritis  is  generally 
present.  It  is  often  impossible  to  determine  the  nature  of 
the  growth  until  the  case  has  been  watched,  or  microscopical 
examination  or  inoculation  experiments  have  been  made. 
These  cases,  which  have  often  been  described  as  granuloma 
of  the  iris,  are  certainly  sometimes  tubercle,  sometimes 
chronic  gummata,  sometimes  part  of  a  severe  so-called 
serous  iritis,  and  sometimes  the  nature  of  the  growth  is 
doubtful.  Inoculation  of  lupous  material  into  the  anterior 
chamber  of  rabbits  has  repeatedly  been  followed  by  the 
formation  of  multiple  nodules,  similar  in  appearance  to 
those  in  some  of  these  cases,  and  some  of  the  growths  in 
human  cases  have  given  the  microscopical  reactions  of  true 
tubercle.  The  disease  is  probably  tubercular  when  the 
grow^ths  are  multiple,  non-vascular,  and  gray,  especially 
when  accompanied  by  enlarged  glands  in  the  patient,  or  a 
family  history  of  tubercle. 


316  NEW -GROWTHS    OF     CONJUNCTIVA. 

Large  masses  of  confluent  tubercle  occasionally  form  in 
the  choroid  or  other  parts  of  the  uveal  tract,  leading  to 
disorganization  of  the  eye,  with  mixed  symptoms  of  intra- 
ocular growth  and  inflammation.  As  it  is  probable  that 
this  ocular  tubercle  maybe  a  source  of  general  tuberculosis, 
excision  of  the  eye  is  the  best  course  in  any  doubtful  case, 
where  it  is  clear  that  the  eye  is  lost. 

The  cornea  is  much  less  liable  to  tubercular  infiltration 
than  the  iris,  but  small  growths  have  been  observed  in  it, 
both  as  the  result  of  inoculation,  and  in  the  course  of  spon- 
taneous tubercle  of  the  iris. 

C.  Tumors  of  the  Orbit,  see  Chap.  XIX. 


CHAPTER     XIX. 

INJURIES,    DISEASES,    AND    TUMORS   OF    THE    ORBIT. 

(1.)  Contusion  and  concussion  injuries — Bruising  of 
the  eyelids  from  direct  blows  ("  black  eye")  may  usually 
with  care  be  distinguished  from  the  deeper  extravasation 
following  fracture  of  the  walls  of  the  orbit.  In  ordinary 
"  black  eye"  the  ecchymosis  comes  very  quickly  and  re- 
mains superficial,  and,  if  it  affect  either  the  palpebral  or 
ocular  conjunctiva,  does  not  pass  far  back.  The  ecchy- 
mosis following  fracture  of  the  orbital  plate  of  the  frontal 
bone  comes  more  gradual!}',  is  deep-seated,  often  entirely 
beneath,  rather  than  in,  the  skin  and  conjunctiva,  dimin- 
ishes in  density  toward  the  front  and  borders  of  the  lids, 
and  when  considerable  causes  proptosis.  But  if  a  fracture 
involve  the  rim  of  the  orbit,  the  above  characters  are  likely 
to  be  mixed  and  therefore  misleading.  Wasting  of  the  adi- 
pose tissue  of  the  orbit,  and  consequent  sinking  back  of  the 
eye,  sometimes  follow  severe  blows,  with  much  extravasa- 
tion of  blood. 

Fracture  of  the  inner  wall  of  the  orbit  into  the  nose,  the 
sinuses  opening  into  it,  or  the  nasal  duct,  is  often  followed 
by  emphysema  of  the  orbital  cellular  tissue.  This  can  occur 
only  when  the  mucous  membrane  is  torn.  The  emphysema 
comes  on  quickly  from  "  blowing  the  nose,"  and  is  shown 
by  a  soft,  whitish,  doughy  swelling  of  the  lids,  Avhich  crepi- 
tates finely  under  the  finger  ;  the  globe  is  more  or  less 
protruded  and  its  movements  limited.  The  emphysema 
disappears  in  a  few  days  if  the  lids  be  kept  bandaged. 
These  fractures  are  usually  caused  by  blows  over  the  inner 


318         INJURIES     AND     DISEASES     OF    ORBIT. 

angle  of  the  orbit,  but  occasionally  by  blows  on  the  malar 
region. 

Partial  ptosis  is  an  occasional  result  of  blows  upon  the 
upper  lid.  It  is  generally  accompanied  by  paralysis  of 
accommodation  and  dilatation  of  the  pupil,  and  it  seldom 
lasts  more  than  a  few  weeks.  Ocular  paralysis  following 
injury  to  the  head  (see  Chap.  XXI.). 

(2.)  Orbital  abscess  and  orbital  cellulitis  may  follow 
injuries,  but  are  often  of  apparently  spontaneous  origin. 
Cellulitis  may  spread  to  the  orbit  from  the  face  in  erysipelas, 
from  the  throat  in  severe  tonsillitis,  or  from  the  socket  of 
an  inflamed  tooth.  Diffused  acute  inflammation  of  the 
cellular  tissue  is  difficult  to  distinguish  from  acute  orbital 
abscess,  since  in  both  there  are  the  signs  of  deep  inflamma- 
tion, with  displacement  of  the  eye,  and  limitation  of  its 
movements,  chemosis  of  the  conjunctiva,  and  brawn}^  swell- 
ing and  redness  of  the  lids.  An  acute  abscess  soon  points 
between  the  globe  and  some  part  of  the  rim  of  the  orbit, 
but  even  in  cellulitis  the  swelling  may  be  greater  at  some 
one  part,  and  give  rise  to  a  feeling  deceptively  like  fluctua- 
tion. 

Orbital  abscess  may  be  so  chronic  as  to  simulate  a  solid 
tumor  until  the  pus  nears  the  surface;  even  then  an  ex- 
ploratory incision  may  be  needed  to  set  the  question  at  rest. 
Abscess  of  the  orbit,whether  acute  or  chronic,  is  very  often 
the  result  of  periostitis,  and  a  large  surface  of  bare  bone  is 
often  found  with  the  probe. 

In  acute  cases,  as  soon  as  fluctuation  is  certain,  an  inci- 
sion is  to  be  made  with  a  narrow,  straight  knife,  generally 
through  the  skin,  or,  if  practicable,  through  the  con- 
junctiva. As  the  pus  is  often  curdy,  it  is  best  not  to  use  a 
grooved  needle.  Chronic  cases  of  doubtful  nature  may  be 
watched  for  a  time.  It  may  be  necessary  to  go  deeply  into 
the  orbit,  either  with  the  knife,  probe,  or  dressing-forceps, 
before  matter  is  reached.     A  drainage-tube  should  be  in- 


INJURIES    AND    DISEASES    OF    ORBIT.        319 

serted  if  the  abscess  be  deep.  The  proptosis  does  not 
always  disappear  when  the  abscess  is  opened,  for  in  addi- 
tion to  hemorrhage  caused  by  the  operation,  there  may  be 
much  thickening  of  the  tissues.  Sight  ma}^  be  injured  or 
lost  by  stretching  of,  or  pressure  on,  the  optic  nerv^e,  and 
the  cornea  may  lose  sensation,  and  ulcerate,  from  damage 
to  the  ciliary  nerves  behind  the  globe. 

Thrombosis  of  the  cavernous  sinus,  which  may  result 
from  several  causes,  produces  local  symptoms  which  it  is 
diflEicult,  often  impossible,  to  distinguish  from  those  of  cel- 
lulitis beo^innino:  in  or  limited  to  the  orbit.  The  thrombosis, 
however,  often  spreads  to  the  other  cavernous  sinus,  and  the 
other  orbit ;  and  in  any  case  it  produces  the  gravest  head 
symptoms,  which,  as  a  rule,  end  fatally  in  a  short  time.^ 
Cases  taking  this  course  are  not  ophthalmic. 

The  lachrymal  gland  is  but  seldom  the  seat  of  inflam- 
mation or  abscess.  In  chronic  cases  the  enlarged  gland  is 
distinctly  felt  projecting,  and  can  generally  be  recognized 
by  its  well-defined  and  lobulated  border ;  but  the  enlarge- 
ment cannot  always  be  distinguished  from  that  caused  by  a 
morbid  growth  in  the  gland  or  corresponding  part  of  the 
orbit.  In  acute  inflammation  there  are  the  usual  signs, 
local  heat,  tenderness,  and  pain,  with  swelling,  which  may 
obscure  the  boundaries  of  the  gland.  If  the  enlargement 
be  great,  the  eyeball  is  displaced,  and  the  oculo-palpebral 
fold  of  the  conjunctiva  in  front  of  the  gland  is  pushed 
downward,  and  projects  more  or  less  between  the  lid  and 
the  eye.  When  an  abscess  forms,  it  usually  points  to  the 
skin,  and  should  seldom  be  opened  from  the  conjunctival 
surface.  If  it  be  allowed  to  burst  spontaneously  through 
the  skin,  a  troublesome  fistula  may  follow.  A  little  abscess 
sometimes  forms  in  one  of  the  separate  anterior  lobules  of 

'  An  able  paper  on  this  little-known  subject  has  been  communicated 
o  the  Ophthalmological  Society  by  Dr.  Sidney  Coupland  (Oct.  1886)  . 


320  INJURIES     AND     DISEASES     OF     ORBIT. 

the  gland.  There  is  limited  swelliDg:  and  tenderness  of  the 
lid  at  the  upper  outer  angle,  not  passing  back  beneath  the 
orbital  rim.  The  abscess  points  through  the  conjunctiva, 
above  the  outer  end  of  the  tarsal  cartilage,  and  is  thus  dis- 
tinguished froTU  a  suppurating  Meibomian  cyst. 

(3.)  Wounds Wounds  of  the  eyelids  need  no  special 

treatment,  beyond  very  careful  apposition  by  sutures, 
sometimes  with  a  small  harelip  pin,  so  as  to  secure  primary 
and  accurate  union.  Lacerated  wounds  of  the  ocular  con- 
junctiva, if  extensive,  need  a  few  fine  sutures,  and  they 
seldom  lead  to  any  deformity.  When  a  rectus  tendon  has 
been  torn  through  I  have  never  succeeded  in  getting  the 
ends  to  unite. 

Penetrating  wounds  through  the  lids  or  conjunctiva, 
M'hicb  pass  deeply  into  the  orbit,  may  be  much  more  seri- 
ous than  they  appear  at  first  sight,  since  the  wounding  body 
may  have  caused  fracture  of  the  orbit,  and  damage  to  the 
brain  membranes,  or  a  piece  of  the  wounding  instrument 
may  have  been  broken  off  and  lie  embedded  in  the  roomy 
cavity  of  the  orbit,  without  at  first  exciting  disturbance  or 
causing  displacement  of  the  eye.  Some  extraordinary  cases 
are  on  record,*  in  which  very  large  foreign  bodies  have 
lain  in  the  orbit  for  a  long  time  undetected.  The  optic 
nerve  is  occasionally  torn  across  without  damage  to  the 
globe.  Every  wound  of  the  ey«!lids  or  conjunctiva  should, 
therefore,  be  carefully  explored  with  the  probe,  and,  when- 
ever possible,  the  instrument  which  caused  the  wound 
should  be  examined. 

When  a  foreign  body  is  suspected  or  known  to  be  firmly 
embedded,  and  is  not  removable  through  the  original 
wound,  it  is  generally  best  to  divide  the  other  canthus,  and 
prolong  the  incision  into  the  conjunctiva  ;  in  some  cases  an 
incision  through  the  skin  over  the  margin  of  the  orbit,  at 

*  In  Mr.  Lawson's  well-known  treatise  and  elsewhere. 


TUMORS     OF     THE     ORBIT.  321 

the  situation  of  the  foreign  body,  will  be  preferable. 
Single  shot,  corns,  embedded  and  causing  no  symptoms, 
should  not  be  interfered  with  unless  they  can  be  easily 
reached. 

Wounds  of  the  orbit,  b}^  gunshot  or  other  explosives, 
when  extensive  and  caused  by  numerous  shots  or  frag- 
ments of  sand,  gravel,  etc  ,  driven  into  the  tissues,  are  of 
course  serious,  particularly  if  the  eyeball  itself  be  injured. 
Such  injuries  may  cause  tetanus. 

Tumors  of  the  Orbit. 

A  tumor  of  any  notable  size  in  the  orbit  always  causes 
protrusion  of  the  eye  (proptosis),  with  or  without  lateral 
displacement  and  limitation  of  its  movement.  As  a  rule 
there  are  no  inflammatory  symptoms.  An  exact  diagnosis 
of  the  seat,  attachments,  and  nature  of  an  orbital  tumor  is, 
of  course,  often  impossible  before  operating;  and  it  may  be 
further  observed  that  there  has  occasionally  been  great 
difficulty  in  deciding  whether  the  symptoms  pointed  to  a 
tumor  or  to  some  form  of  chronic  hypertrophy  of  cellular 
tissue  or  quiet  gummatous  inflammation. 

A  tumor  in  the  orbit  may  originate  in  some  of  the  loose 
orbital  tissues,  in  the  lachrymal  gland,  in  the  periosteum, 
upon  or  within  the  eyeball,  or  from  the  optic  nerve ;  or  it 
may  have  encroached  upon  the  orbit  from  one  of  the  neigh- 
boring cavities.  Fluctuating  tumors  in  the  orbit  may  be 
cystic  or  ill-defined,  and  may  or  may  not  pulsate.  Solid 
tumors  in  the  orbit  may  be  movable,  or  be  fixed  by  broad 
attachments  to  the  wall  of  the  cavity.  Sight  is  often  dam- 
aged or  destroyed  in  the  corresponding  eye  by  compression 
or  infiltration  in  the  optic  nerve. 

(1.)  Distention  of  the  frontal  sinus  by  retained  mucus 
causes  a  well-marked,  fixed,  usually  very  chronic  swelling, 
not  adherent  to  the  skin,  at  the  upper  inner  angle  of  the 

14* 


322         INJURIES     AND     DISEASES     OF     ORBIT. 

orbit  above  the  tendooculi.  Hard  at  first,  it  fluctuates  when 
the  bony  wall  has  been  absorbed.  Its  course  is  usually  slow, 
but  acute  suppuration  may  supervene,  and  the  swelling  be 
mistaken  for  a  lachrymal  abscess.  There  is  generally  a 
remote  history  of  injury.  The  aim  of  treatment  is  to  re- 
establish the  opening,  closed  probably  as  the  result  of 
fracture,  between  the  floor  of  the  sinus  and  the  nose.  The 
most  prominent  part  of  the  sw^elling  is  freely  opened ;  a 
finger  is  then  passed  up  the  nostril  and  the  floor  of  the 
sinus  perforated  on  the  finger  by  a  scissor  or  trocar  passed 
from  above  through  the  incision.  A  seton  or  drainage- 
tube  is  then  passed  through  the  hole,  brought  out  at  the 
nostril,  and  must  be  worn  for  several  weeks  or  months. 

(2.)  Pedunculated  ivory  exostoses  sometimes  grow  from 
the  walls  of  the  same  sinus  or  its  neighborhood ;  beginning 
early  in  life  they  increase  very  slowly,  cause  absorption  of 
their  containing  walls,  and  often  in  the  end  undergo  spon- 
taneous necrosis  and  fall  out.  Their  removal  while  still 
fixed  is  very  difficult  and  dangerous,  owing  to  the  prox- 
imity of  the  dura  mater. 

(3.)  Tumors  encroaching  on  one  or  both  orbits  from  the 
base  of  the  skull,  the  antrum,  the  nasal  cavity,  or  the  tem- 
poral fossa,  generally  admit  of  correct  diagnosis. 

The  suspicion  of  tumor  on  the  inner  or  lower  wall  of  the 
orbit  should  always  lead  to  an  examination  of  the  palate, 
pharynx,  and  teeth,  of  the  permeability  of  each  nostril,  of 
the  functions  of  the  cranial  nerves,  of  the  state  of  the  glands 
behind  the  jaw  on  both  sides,  and  to  an  inquiry  as  to  epi- 
staxis  or  discharge  from  the  nose. 

(4.)  Pulsating  tumors  of  the  orbit  and  cases  of  proptosis 
with  pulsation  are  in  most  cases  due  to  arterio-venous  in- 
ter-communication in  the  cavernous  sinus,  in  consequence 
of  which  the  ophthalmic  vein  and  its  branches  become 
greatly  distended  with  partially  arterialized  blood.  In  a 
large  proportion  the  symptoms  follow  rather  gradually  after 


TUMORS     OF     THE     ORBIT.  323 

a  severe  injury  to  the  head.  In  others  they  come  on  sud- 
denly with  pain  and  noises  in  the  head,  without  apparent 
cause,  and  these  idiopathic  cases  are  usually  in  senile  per- 
sons. In  several  examples  of  both  forms  a  communication 
has  been  found,  post  mortem,  between  the  internal  carotid 
artery  and  the  cavernous  sinus,  the  result  of  wound  from 
fracture  of  the  base  of  the  skull  in  the  traumatic  cases, 
and  of  rupture  of  an  aneurism  in  the  idiopathic  ones.  The 
typical  symptoms  are  proptosis,  withchemosis,  pulsation  of 
the  eyeball,  paralysis  of  orbital  nerves,  a  soft  pulsating 
tumor  under  the  inner  part  of  the  orbital  arch,  and  a  bruit. 
A  bruit  with  proptosis  and  conjunctival  swelling  may  be 
present  without  demonstrable  tumor  of  pulsation.  Liga- 
ture of  the  common  carotid  has  been  practised  with  good 
results  in  a  large  number  of  cases ;  subsequent  excision  of 
the  eye  and  evisceration  of  the  orbit  for  a  dangerous  return 
of  symptoms  in  one  or  two.  An  unruptured  aneurism  of 
the  internal  carotid  does  not  cause  the  symptoms  just 
described.  Aneurism  of  the  intra-orbital  arteries  and 
arterio-venous  communications  in  the  orbit,  if  they  occur, 
are  excessively  rare.  Erectile  tumors,  well  defined  and 
separable,  but  not  causing  decided  pulsation,  are  some- 
times met  with  in  the  orbit,  and  can  be  dissected  out. 

(5.)  A  fluctuating  tumor  which  does  not  pulsate,  is  not 
inflamed,  and  not  connected  with  the  frontal  sinus,  may  be 
a  chronic  orbital  abscess,  a  hydatid,  or  a  cyst  containing 
bloody  or  other  fluid  and  of  uncertain  origin.  An  explora- 
tory puncture  should  be  made  after  sufficiently  watching 
the  case,  and  the  further  treatment  must  be  conditional. 
Perfectly  clear,  thin  fluid  probably  indicates  a  hydatid,  and 
in  this  case  the  swelling  is  likely  to  return  after  a  puncture, 
and  the  cyst  will  need  removal  through  a  free  opening. 
The  echinococcus  hydatid  often  contains  daughter-cysts, 
some  of  which  escape  puncture.  Suppuration  may  take 
place  around  any  species  of  hydatid. 


324  INJURIES     AND     DISEASES     OF     ORBIT. 

(6.)  Examination  leads  to  the  diagnosis  of  a  solid  tumor 
limited  to  the  orbit.  We  must  try  to  determine  whether  the 
growth  began  in  the  eyeball  or  optic  nerve,  or  in  some  of 
the  surrounding  tissues.  We  therefore  examine  the  globe 
for  symptoms  of  intra-ocular  tumor. 

Solid  growths  independent  of  the  eyeball  may  arise  as 
follows:  (a)  From  the  periosteum;  these  are  firmly  attached 
by  a  broad  base,  are  generally  malignant,  and  seldom  admit 
of  successful  removal.  (6)  The  lachrymal  gland  may  be 
the  seat  of  various  morbid  growths,  including  carcinoma; 
a  great  part  of  the  growth  is  in  the  position  of  the  gland, 
and  can  be  explored  by  the  finger.  Although  such  a 
growth  is  often  attached  firmly  to  the  orbital  wall,  its  posi- 
tion, lobulated  outline,  and  well-defined  boundary  will  often 
lead  to  a  correct  diagnosis.  Tumors  of  the  lachrymal  gland 
should  always  be  removed  if  they  are  increasing,  for  we  can 
never  feel  sure  that  they  are  innocent,  (c)  Solid  tumors 
originating  in  some  of  the  softer  orbital  tissues,  especially 
the  form  known  as  cylindroma,  or  plexiform  sarcoma,  occur 
more  rarely,  {d)  Tumors  of  the  optic  nerve,  usualh^  myxo- 
matous, occur,  though  rarely  •/  they  generally  cause  neuro- 
retinitis  and  blindness,  but  no  absolutely  pathognomonic 
symptoms ;  they  may  sometimes  be  extirpated  without  re- 
moving the  globe. 

When  an  orbital  tumor  is  found  during  operation  to  be 
adherent  to  bone  or  to  infiltrate  the  soft  parts,  chloride  of 
zinc  paste  (F.21)  should  be  applied  on  strips  of  lint,  either 
at  once  or  the  next  day  when  oozing  has  ceased.  If  the 
periosteum  be  affected  it  is  to  be  stripped  ofiT,  and  the  paste 
applied  to  the  bare  bone.  Hemorrhage  from  the  depth  of 
the  orbit  can  always  be  controlled  by  perchloride  of  iron 
and  a  firm,  graduated  compress. 

In  every  case  of  suspected  primary  orbital  tumor  the 

'  For  references  eee  Knapp'e  Archives  of  Ophthalmology,  xii.  292. 


TUMORS     OF     THE     ORBIT.  325 

question  of  syphilis  must  be  carefully  gone  into  ;  although 
neither  periosteal  nor  cellular  nodes  are  common  in  the 
orbit,  both  are  known  to  occur,  and  disappear  under  proper 
treatment. 

Naevus  may  occur  on  the  eyelids  and  in  the  orbit,  and 
implicate  the  conjunctiva,  both  of  the  lids  and  eyeball. 
Deep  naevi  may  degenerate  and  become  partly  cystic.  Some 
cases  of  naevus  of  the  face  are  associated  with  nsevus  of  the 
choroid ;  in  such,  the  eyes  are  generally  very  defective. 

Dermoid  tumors  (cystic)  are  not  uncommon  at  the  outer 
end  of  the  eyebrow  ;  more  rarely  they  occur  near  the  inner 
canthus.  Lying  deeply,  beneath  the  orbicularis,  they  are 
not  adherent  to  the  skin,  like  sebaceous  cysts ;  the  subja- 
cent bone  sometimes  is  hollowed  out.  They  often  grow 
faster  than  the  surrounding  parts,  and  should  then  be  ex- 
tirpated, the  thin  cyst-wall  being  carefully  and  completely 
removed  through  an  incision  parallel  with,  and  situated 
in,  the  eyebrow.  They  usually  contain  sebaceous  matter 
and  short  hairs;  occasionally,  clear  oil. 


CHAPTER   XX. 

ERRORS   OF    REFRACTION    AND    ACCOMMODATION. 

As  stated  at  p.  38,  §  19,  when  the  length  of  the  eye  is 
normal,  and  the  accommodation  relaxed,  only  parallel  rays 
are  focussed  on  the  retina,  and,  conversely,  pencils  of  rays 
emerging  from  the  retina  are  parallel  on  leaving  the  eye, 

Fig. 103. 


Pencils  of  parallel  rays  entering  or  emerging  from  an  emmetropic  eye. 

Fig.  102,  and  this,  the  condition  of  the  normal  eye  in 
distant  vision,  is  called  emmetropia  (E.).  All  permanent 
departures  from  the  condition  in  which,  with  relaxed 
accommodation,  the  retina  lies  at  the  principal  focus,  are 
known  collectively  as  ametropia. 

In  E.,  rays  from  any  near  object,  e.  g.,  divergent  rays 
from  Ob,  Fig.  103,  are  focussed  behind  the  retina  at  cf, 
every  conjugate  focus  being  beyond  the  principal  focus. 
Reaching  the  retina  before  focussing,  such  rays  will  form 
a  blurred  image,  and  the  object  Ob  will  therefore  be  seen 
dimly.  But  by  using  accommodation  the  convexity  of  the 
crystalline  lens  can  be  increased  and  its  focal  length  short- 
ened, so  as  to  make  the  conjugate  focus  of  Ob  coincide 


MYOPIA.  82T 

exactly  with  the  retina  (cf,  Fig.  104).     Under  this  con- 
dition the  object  Ob  will  be  clearly  seen,  whilst  the  focus 

Fig.  103. 


Emmetropia.    Distant  objects  (parallel  raj's)  focussed  on  retina  ;  near 
objects  (divergent  rays)  focussed  behind  retina. 

of  a   distant  object,  formed  in  Fig.  103   on  the   retina, 
will  now  lie  in  front  of  it  (f,  Fig.  104),  and  the  distant 

Fig.  104. 


Eye  during-  accommodation.  Near  objects  (divergent  rays)  focussed 
on  retina  ;  distant  objects  (parallel  rays)  focussed  in  front  of  retina. 
The  dotted  line  in  front  of  the  lens  shows  its  increase  of  convexity. 

object  will  appear  indistinct.  The  nearest  point  of  dis- 
tinct vision  (jj)  and  the  farthest  (?')  have  been  defined  at 
p.  49. 

Myopia  (M.). 

In  Fig.  103,  if  the  retina  were  at  cf  instead  of  at  f,  a 
clear  image  would  be  formed  on  an  object  at  Ob  without 
any  effort  of  accommodation,  whilst  objects  farther  off 
would  be  focussed  in  front  of  the  retina.  This  state,  in 
which  the  posterior  part  of  the  eyeball  is  too  long,  so  that, 
with  the  accommodation  at  rest,  the  retina  lies  at  the  con- 


328         RKFRAOTION     AND     ACCOMMODATION. 

jugate  focus  of  an  object  at  a  comparatively  small  distance, 
is  called  Short-sig'ht  or  Myopia  (M.),  Axial  Myopia. 

In  Fig.  105  the  inner  line  at  r.  is  the  retina,  and  f  the 
principal  focus  of  the  lens-system,  i.  e.,  the  position  of  the 
retina  in  the  normal  eye.  Rays  emerging  from  r  will,  on 
leaving  the  eye,  be  convergent,  and,  meeting  at  the  conju- 

FiG.  105. 


Myopia.     Retina  beyond  principal  focus,  hence  only  near  objects 
(divergent  rays)  focussed  on  retina. 


gate  focus  r',  will  form  a  clear  image  in  the  air.  Con- 
versely, an  object  at  r'  will  form  a  clear  image  on  the 
retina  (r).  The  image  of  every  object  at  a  greater  dis- 
tance than  r'  will  be  formed  more  or  less  in  front  of  r, 
and  every  such  object  must,  therefore,  be  seen  indistinctly. 
But  objects  nearer  than  r'  will  be  seen  clearly  by  exerting 
accommodation,  just  as  in  the  normal  eye.  Figs.  103  and 
104. 

In  M.  the  indistinctness  of  objects  beyond  the  far  point 
(r)  is  lessened  by  partially  closing  the  eyelids.  This  habit 
is  often  noticed  in  short-sighted  people  who  do  not  wear 
glasses,  and  from  it  the  word  myopia  is  derived. 

The  distance  of  ?'  (r^  Fig.  105)  from  the  eye  will  depend 
on  the  distance  of  its  conjugate  focus  r,  i.  e.,  upon  the 
amount  of  elongation  of  the  eye.  The  greater  the  distance 
of  R  beyond  f,  the  less  will  be  the  distance  of  its  conjugate 
focus  r'  (  =  r)  ;  in  other  words,  the  higher  will  be  the  M., 
and  the  more  indistinct  will  distant  objects  be.  If  the 
elongation  of  the  eye  be  very  slight,  R  nearly  coinciding 


MYOPIA.  329 

with  F,  R''  (=?')  will  be  at  a  much  greater  distance,  and 
distant  objects  will  be  less  indistinct.  As  the  retinal 
images  formed  in  a  myopic  eve  are  larger  than  normal, 
myopic  persons  can  distinguish  smaller  objects  at  the  same 
distance  as  those  with  normal  eyes. 

SYiiPTOMS  OF  M. — In  low  degrees  the  patient's  com- 
plaint is  that  he  cannot  see  distant  objects  clearly  ;  in 
moderate  and  high  degrees  it  is  rather  that  he  can  see  dis- 
tinctly only  when  things  are  held  very  close,  for  objects  a 
few  feet  off  are  so  indistinct  that  many  such  persons  neglect 
them.  Adults  often  tell  us  that  their  distant  sight  was 
good  till  about  eight  or  ten  years  of  age,  that  it  then  began 
to  shorten,  and  that  the  defect,  after  increasing  for  several 
years,  at  length  became  stationary. 

In  high  degrees  of  M.  the  patient  is  apt  to  complain  of 
special  difficulty  in  seeing  at  night,  probably  because — (1) 
the  mobility  of  the  eye  being  below  normal,  the  field  of 
fixation  is  diminished,  and  (2)  the  elongation  of  the  eye  by 
altering  the  position  of  the  retina  leads  to  some  narrowing 
of  the  field  of  indirect  vision.^ 

In  many  cases  no  other  complaint  is  made,  but  in  a  cer- 
tain number  complications  are  present.  There  is  often  in- 
tolerance of  light,  an  additional  cause  for  the  half-closed 
lids  and  frowning  expression  so  often  noticed.  Aching  of 
the  eyes  is  a  very  common  and  troublesome  symptom, 
and  is  especially  frequent  if  the  M.  is  increasing ;  it  is 
often  brought  on,  and  always  made  worse,  by  over-use  of 
the  eyes,  but  sometimes  it  is  very  troublesome  when  quite 
at  rest,  and  even  in  bed  at  night.  One  or  both  internal 
recti  often  act  defectively,  so  that  convergence  of  the  optic 
axes  for  near  vision  becomes  difficult,  painful,  or  impos- 
sible, and  various  degrees  of  divergent  strabismus  result ; 

^  Wecker  and  Laudolt,  Traite,  T.  1,  i.  p.  595.  Landolt,  Refraction 
and  Accommodation  of  the  Eye,  p.  425. 


330        REFRACTION     AND     ACCOMMODATION. 

this  occurs  oftcnest,  but  by  no  means  only,  in  the  higher 
degrees  of  M.,  where  r  is  so  near  that  binocular  vision 
involves  a  strong  effort  of  convergence.  When  this  "mus- 
cular asthenopia,"  or  "insufficiency  of  the  internal  recti," 
is  slight  or  intermittent  it  causes  indistinctness  or  "danc- 
ing" of  the  print,  sometimes  actual  diplopia,  beside  the 
other  discomforts  mentioned  ;  but  diplopia  is  seldom  present 
when  a  constant  divergent  squint  has  been  established. 

This  tendency  to  divergence  in  M.  is  also  partly  due  to  the 
natural  association  between  relaxation  of  the  ciliary  muscles 
and  of  the  internal  recti — the  converse  of  convergent  squint 
iuH. 

The  lower  degrees  of  M.  are  sometimes  accompanied  by 
involuntary  contraction  of  the  ciliary  muscle,  "spasm  of 
accommodation,"  by  which  M.  is  tcmporaril}^  increased; 
and  the  habitual  approximation  of  objects  which  thus  be- 
comes necessary  is  one  cause  of  still  further  elongation  of 
the  eye  and  increase  of  the  structural  M. 

Floating  specks,  muscae  volilantes,  are  especially  common 
and  troublesome  in  myopia. 

Fig.  106. 


Section  of  a  highly  myopic  eyeball.    The  retina  has  been  removed. 

Objective  Signs  and  Complications. — In  high  de- 
grees of  M  the  sclerotic  is  enlarged  in  all  directions,  Fig. 
106  ;  the  eye  being  too  large  often  looks  too  prominent, 
and  its  movements  are  somewhat  impeded.  But  apparent 
prominence  of  the  eye  may  depend  on  many  other  causes. 


MYOPIA.  331 

The  existence  of  M.  is  made  certain  by  the  ophthalmo- 
scope in  four  dififerent  ways :  (1.)  By  direct  examination, 
the  image  of  the  fundus  formed  in  the  air,  Fig.  105,  is 
clearly  visible  to  the  observer  if  he  be  not  nearer  to  it  than 
his  own  near  point.  The  image  is  inverted  and  magnified, 
the  enlargement  being  greater  the  further  it  is  formed  from 
the  patient's  eye,  i.  e.,  the  lower  the  M.  For  very  low  de- 
grees this  test  is  not  easy  to  use,  because  of  the  great  dis- 
tance (3^  or  4',  e.  g.)  that  must  intervene  between  observer 
and  patient ;  but  it  is  easily  applied  if  the  image  be  not 
more  than  2'  in  front  of  the  patient. 

(2.)  By  indirect  examination  the  disc  in  M.  appears 
smaller  than  usual.  If  now  the  object  lens  be  gradually 
withdrawn  from  the  patient's  eye,  the  disc  will  seem  to 
grow  larger.  This  appearance,  which  depends  on  a  real 
increase  in  the  size  of  the  aerial  image,  is  less  evident  the 
lower  the  M.,  Fig.  108,  C. 

(3.)  By  direct  examination  no  clear  view  of  the  fundus 
is  obtained  if  the  distance  between  the  patient  and  observer 

Fig.  107. 


Myopic  crescent  or  small  posterior  staphyloma.    (  Wecker  and  Jaeger.) 

be  less  than  that  between  patient  and  inverted  aerial  image, 
Figs.  32  and  105,  r';  and  as  r'  is  in  front  of  the  myopic 
eye  the  image  will  always  be  invisible  if  the  observer  go 
close  to  the  patient.  Hence,  if  on  going  close  to  the 
patient  the  observer  cannot,  either  by  relaxing  or  using 
his  accommodation,  see  anv  details  of  the  fundus  clearly, 


332         REFU ACTION     AND     ACCOMMODATION 
Fig.  108. 


MYOPIA.  333 

Description  of  Fig.  108.  This  figure  exhibits  the  effect  on  the  size  of 
the  inverted  image  caused  by  withdrawing:  the  objective  lens  from  the 
eye,  in  the  indirect  ophthalmoscopic  examination. 

A  shows  that  in  emmetropia  the  imag^e  remains  of  the  same  size  on 
withdrawal  of  the  lens.  Ob  is  the  retina  lying  at  the  principal  focus 
of  the  dioptric  media  of  the  eye,  represented  by  l  ;  I  and  I'  show  the 
objective  lens  at  different  distances  from  the  eye  ;  Im  and  Im'  the  oph- 
thalmoscopic images  formed  in  each  case.  Rays  from  any  point  on  06 
emerge  from  l  parallel,  and  are  united  by  I  at  the  point  Im  (the  prin- 
cipal focus  of  I  for  the  rays  indicated)  on  the  secondary  axis  i,  which 
forms  with  the  principal  axis  the  angle  a.  If  I  be  removed  to  V  it  will 
still  intercept  some  of  the  same  bundle  of  parallel  rays,  and  these  will 
be  united  in  Im\  at  the  same  distance  as  before,  on  the  secondary  axis 
2,  which  forms  with  the  principal  axis  the  angle  6  =  the  angle  a.  The 
relative  sizes  of  Jmand  Im'  depend  on  (1)  their  respective  distances,  d 
and  cV ,  from  the  lens,  and  (2)  on  the  size  of  the  angles  a  and  b.  As 
in  the  present  case  d  =  d'  and  a=b,  Im  must  =  Ln', 

B  shows  the  diminution  of  the  image  in  hypermetropia.  The  letter- 
ing is  as  before,  but  f  is  the  principal  focus  of  l,  and  v.r.  the  virtual 
focus  of  the  retina  Ob.  The  letters  d  and  d'  are  omitted,  but  can  easily 
be  supplied.  The  angle  &  is  now  smaller  than  a,  because  the  rays 
emerge  from  l  divergent  (as  if  from  v.f.),  and  hence  {d  and  d'  being 
nearly  equal)  Im'  must  be  smaller  than  Im. 

C  shows  the  increase  of  the  image  in  myopia  :  the  retina,  Ob,  is  now 
beyond  r;  c.r.  is  the  "  far  point"  of  the  eye,  conjugate  to  Ob.  The 
angle  b  is  now  larger  than  a  because  the  rays  emerge  from  l  conver- 
gent (toward  c.r.),  and  hence  (d  and  d'  still  being  nearly  equal)  Im' 
must  be  larger  than  Im. 


the  patient  is  myopic,  opacities  of  the  media  being,  of 
course,  excluded.  This  test  is  applicable  to  all  degrees  of 
M.,  accommodation  being  completely  relaxed. 

(4.)  By  retinoscopy  with  concave  mirror  (p.  82),  the 
shadow  obtained  on  rotating  the  mirror  moves  in  the  direc- 
tion of  rotation.  The  tests  (1),  (2),  and  (4)  are,  on  the 
whole,  most  generally  useful  for  beginners. 

In  a  large  proportion  of  cases  the  elongation  of  the  eye 
causes  atrophy  of  the  choroid  on  the  side  of  the  optic  disc 
next  to  the  y.  s.,  the  apparent  inner  side  in  indirect  exam^i- 
nation.    This  atrophy  gives  rise  to  a  crescentic  pateh,  Fig. 


334 


REFRACTION     AND    ACCOMMODATION. 


107,  of  yellowish-white  or  grayish  color,  whose  concavity 
is  formed  by  the  border  of  the  disc,  whilst  its  convex  side 
curves  towards  they.  s. ;  it  is  known  as  a  "myopic  crescent," 
also  as  a  "  posterior  staphyloma,"  because  it  indicates  a 
localized  bulging  of  the  sclerotic,  Fig.  106.  It  varies  in 
size  from  the  narrowest  rim  to  an  area  several  times  that 
of  the  disc,  and  may  form  a  zone  entirely  surrounding  the 
disc.  Fig.  109,  instead  of  a  crescent;  there  may  also  be 
several  spots  of  atrophied  or  thinned  choroid  beyond  the 
bounds  of  the  crescent,  and  these  are  apt  to  occur  in  hori- 
zontal lines  near  the  y.  s.  Extensive  choroidal  changes 
are  generally  assumed  to  be  the  result  of  choroiditis,  "my- 
opic choroiditis."     As  a  rule,  the  higher  the  M.  the  more 


Fig.  109. 

Tffllf'f|f"'f)|[7mrT 


Large  annular  posterior  staphyloma.     (Liebreich.) 


extensive  are  the  choroidal  changes,  but  the  relation  is  by 
no  means  constant,  and  occasionally  even  in  high  degrees 
we  find  no  crescent.  Hemorrhages  may  occur  from  the 
choroid  in  the  same  region,  and  leave  some  residual  pig- 
ment. Owing  to  the  steepness  of  the  bulging  the  disc  is 
often  tilted  and  appears  oval  because  seen  at  "  three-quarter 
face"  instead  of  "full  face,"  Fig.  109.     It  is  sometimes 


MYOPIA.  335 

very  pale  on  the  side  next  the  y.  s.  when  the  staphyloma 
is  large. 

There  is  in  M.  a  great  liability  to  liquefaction  of,  and 
the  formation  of  opacities  in,  the  vitreous,  and,  still  worse, 
to  detachment  of  the  retina  A  large  proportion  of  all 
retinal  detachments  occur  in  myopic  eyes.  A  blow  on 
the  eye  sometimes  appears  to  have  caused  the  detachment, 
though  often  not  until  after  a  considerable  interval.  In 
high  degrees  of  M.  the  lens  frequently  becomes  cataractous, 
the  cataract  generally  being  cortical  and  complicated  with 
disease  of  the  vitreous. 

Thus  we  arrive  at  a  sum  total  of  serious  diflSculties  and 
risks  to  which  myopic  persons  are  subject,  especially  when 
the  myopia  is  of  high  degree.  It  is  only  when  the  degree 
is  low  (2  D.  or  less),  and  the  condition  stationary,  that  the 
popular  idea  of  "short  sight"  being  "strong  sight"  is  at  all 
borne  out,  or  that  the  later  onset  of  Pr.  counterbalances 
the  disadvantages  of  bad  distant  vision. 

Causes. — M.  is  very  rarely  present  at  birth.  The 
elongation  of  the  globe  which  constitutes  M.  comes  on 
gradually  during  the  growing  period  of  life,  and  especially 
between  the  ages  of  ten  and  twenty;^  the  eye  begins  to 
elongate  during  childhood.  Though  M.  is  strongly  heredi- 
tary, it  may  also  begin  independently,  especially  from  the 
prolonged  use  of  the  eyes  for  near  w^ork.  The  strain  on 
the  internal  recti,  counterbalanced,  it  may  be,  by  a  cor- 
responding tension  on  the  external  recti,  is  believed  to  act 
by  compressing  the  eyeball,  and  thus  causing  the  unpro- 
tected posterior  pole  of  the  sclerotic  to  bulge  The  con- 
comitant tension  of  the  ciliary  muscle  probably  aids  by 
bringing  on  congestion  of  the  uveal  tract  (as  it  certainly 
appears  to  do  of  the  disc),  and  thus  predisposes  to  softening 

1  Recent  examinations  by  Schleich  and  Germann  upon  several 
hundred  infants  show  that  the  human  eye  is  almost  invariably  hyper- 
metropic at  birth. 


336         REFRACTION     AND     ACCOMMODATION. 

and  yielding  of  the  tunics;  to  this  congestion  the  habit  of 
stooping  over  the  book  or  work  contributes  by  retarding 
the  return  of  blood.  It  is  evident  that  if  such  causes  are 
able  to  start  the  disease  they  must  constantly  tend  to 
increase  it.  M.  seldom  increases  after  the  age  of  twenty- 
five,  unless  under  special  circumstances;  but  general  en- 
feeblement  of  health,  as  after  severe  illness  or  prolonged 
suckling,  seriously  increases  the  risk  of  its  progress,  even 
after  middle  life.  Any  condition  in  which  during  child- 
hood better  vision  is  gained  by  holding  objects  very  close  is 
likely  to  bring  on  M. ;  and  so  we  find  it  disproportionately 
common  amongst  those  who  from  childhood  have  suffered 
from  corneal  nebulae,  partial,  especially  lamellar,  cataract, 
severe  choroiditis,  or  a  high  degree  of  astigmatism.  A  bad 
supply,  or  bad  management,  of  light,  bad  print,  and  seats 
or  desks  so  proportioned  as  to  encourage  children  to  stoop 
over  their  lessons,  are  now  generally  believed  to  be  largely 
answerable  for  the  production  of  myopia.  It  is,  however, 
to  be  noted  that  some  of  the  very  worst  cases  occur  in  per- 
sons who  have  never  used  their  eyes  for  close  observation 
of  any  kind. 

Treatment. — The  treatment  is  divisible  into  (1)  pro- 
phylactic and  (2)  remediable.  1.  Much  may  be  done  to 
prevent  M.,  or  to  check  its  increase  when  it  has  begun,  by 
regulating  the  light,  books,  and  desks  used  by  children,  so 
as  to  remove  the  temptations  to  stooping.  Children  should 
not  be  allowed  to  read  or  work  by  flickering  or  dull  light; 
and  as  we  write  and  read  from  L.  to  R.  it  is  best,  whenever 
possible,  to  admit  the  light  from  the  left,  so  that  the  shadow 
of  the  pen  is  thrown  toward  the  right,  away  from  the  object 
looked  at.  A  myopic  child  should  not  be  allowed  fully  to 
indulge  his  bent,  which  is  generally  strong,  for  excessive 
reading.  2.  By  means  of  suitable  glasses  (a)  distant 
objects  may  be  seen  clearly,  i.  e.,  the  eye  b3  rendered  em- 
metropic. (6)  reading  and  working  become  possible  at  a 


MYOPIA.  337 

n^reater  distance.  The  strain  on  the  internal  recti  usually 
ceases  when  the  gaze  is  directed  into  the  distance,  whether 
vision  be  distinct  or  not;  glasses  for  distant  vision  have, 
therefore,  no  effect  on  the  progress  of  the  myopia,  and  are 
of  value  only  for  educational  purposes,  that  the  patient  may 
see  what  is  about  him  as  clearly  as  other  people;  their  use 
is,  therefore,  to  a  great  extent  optional.  But  if  we  can 
increase  the  distance  of  the  natural  far  point  (r)  from  the 
eyes,  we  lessen  the  tension  on  the  internal  recti  in  near 
vision,  diminish  the  temptations  to  stooping  and  to  reading 
by  bad  light,  and  so  help  to  check  the  progress  of  the  dis- 
ease ;  hence  glasses  for  near  work  are  very  important  in 
the  higher  degrees  of  M.  (3  D.  and  more)  in  early  life. 
When  M.  has  been  stationary  for  years,  however,  the  de- 
cision even  on  this  point  may  be  left  to  the  patient. 

Before  ordering  glasses  for  either  purpose  we  must 
measure  accurately  the  degree  of  M.  In  Fig.  110  let  r  be 
the  far  point,  and  let  it  be  25  cm.  in  front  of  the  patient's 
eye,  so  that  he  can  see  nothing  clearly  at  a  greater  distance 
than  25  cm.  (a)  Re  is  required  to  see  distant  objects 
(objects  seen  under  parallel  rays)  clearly.  A  concave  lens 
is  interposed  of  strength  sufficient  to  give  to  parallel  rays  a 
degree  of  divergence,  as  if  they  came  from  r,  Fig.  110.  The 
focal  length  of  this  lens  will  be  the  same  as  its  distance 
from  r ;  and,  as  it  is  placed  close  to  the  eye,  its  focal 
length  will  be  very  nearly  the  same  as  (a  little  shorter  than) 
the  patient's  far  point.  Therefore,  if  we  measure  the  dis- 
tance of  r  from  the  patient's  eye,  a  lens  of  nearly  the  same 
focal  length  will  neutralize  his  M.  He  will  choose  a  lens 
rather  higher  than  this  test  would  lead  us  to  expect,  if  the 
M.  be  uncomplicated ;'  whilst  if,  owing  to  complications. 

'  It  is  sometimes  stated  that  the  glass  chosen  for  distance  is  rather 
weaker  i^mn  is  indicated  by  the  distance  of  r  from  the  crystalline  lens, 
the  accommodation  caueins:  an  apparent  increase  of  M.  This  is  true 
only  in  low  de^r^es  of  M,,  and  not  always  in  them  :  most   patients 

1.=' 


338         REFRACTION     AND     ACCOMMODATION. 

there  be  considerable  defect  of  vision,  be  will  often  choose 
a  somewhat  lower  glass.  Hence,  it  is  a  good  riile  to  begin 
the  trial  with  a  lens  weaker  than  the  one  which,  judging 

Fig.  110. 


Myopia  corrected  by  concave  lens. 

by  the  above  test,  we  expect  the  patient  to  choose,  and  to 
try  successively  stronger  ones  till  the  best  result  is  reached. 
The  weakest  concave  glass  w^hich  gives  the  best  attainable 
sight  for  the  distant  test  types  is  the  measure  of  the  M., 
and  this  glass,  hut  not  a  stronger  one,  may  be  safely  worn 
for  distant  vision.  Beginners  often  test  M.  patients  with 
concave  glasses  for  near  types;  neither  +  nor  — glasses 
give  any  information  about  the  refraction  when  used  for 
near  objects,  since  they  merely  either  substitute,  or  call 
into  use,  the  accommodation. 

(b)  A  glass  is  needed  with  which  the  patient  will  be  able 
to  read  or  sew  at  a  distance  greater  than  his  natural  far 
point.  Theoretically  the  fully  correcting  glass  (a)  would 
suit,  since  it  gives  to  all  rays  a  course  w^hich,  in  relation  to 
the  myopic  eye,  is  the  same  as  that  of  the  raj^s  entering  a 
normal  eye.  But  this  glass  can  seldom  safely  be  allowed 
in  the  higher  degrees  of  M.  The  lens  which  fully  corrects 
the  myopia  diminishes  the  size  of  the  retinal  images  so 
much  that  the  patient  is  tempted  to  enlarge  them  again  by 

choose  rather  stronger  lens  than  is  indicated  by  r — i.  e.,  a  lens  whose 
focus  is  shorter  by  the  distance  between  its  own  central  point  and  the 
cornea. 


MYOPIA.  339 

bringing  the  object  nearer ;  again,  the  accommodation  is 
often  defective  in  the  higher  degrees  of  M.,  and,  as  the  fully- 
correcting  lens  requires  full  accommodation,  it  will  lead  to 
over-straining  if  this  function  be  weakened,  and  so  cause 
discomfort,  if  nothing  worse.  For  these  two  reasons  the 
rule  is  to  give,  for  near  work,  a  glass  which  will  diminish 
the  myopia,  but  not  fully  correct  it.  Glasses  for  near  work 
are  seldom  needed  unless  M.  exceed  3  D. 

Let  M.  be  7  D.  then  r  will  be  at  14  cm.  (p.  40)  from  the 
eye.  If  a  glass  be  required  with  which  the  patient  shall 
be  able  to  read  at  30  cm.,  or  which  shall  remove  r  from  14 
em.  to  30  cm.,  i.  e.,  shall  leave  the  patient  with  M.  3  D., 
we  must  correct  the  difference  between  7  D.  and  3  D.  (7 
D. — 3  D.=4  D.);  a  concave  lens  of  4  D.  will  make  rays 
from  30  cm.  diverge  as  if  they  came  from  14  cm.  But 
even  this  partial  correction  may  diminish  the  images  so 
much  that,  if  vision  be  imperfect,  from  extensive  choroidal 
changes,  reading  at  the  increased  distance  will  be  difficult, 
and  the  patient  will  prefer  to  bring  the  object  nearer  again 
at  the  expense  of  his  accommodation,  and  will  thus  be  in- 
convenienced instead  of  bettered ;  it  is,  therefore,  often 
advisable,  even  for  partial  correction,  to  order  a  weaker 
lens  than  is  optically  correct. 

Aching  from  preponderance  of  the  external  over  the 
internal  recti  (insufiBciency  of  the  internal  recti),  if  not 
cured  by  partially  correcting  glasses,  is  often  best  treated 
by  division  of  the  external  rectus  of  one  or  both  eyes. 
This  operation  may  always  be  done  when  there  is  a  marked 
divergent  squint,  even  if  the  squint  be  variable.  Prismatic 
spectacles  (p.  35),  the  bases  of  the  prisms  being  toward  the 
nose,  are  very  serviceable  for  reading  in  cases  of  slight 
muscular  insufficiency.  By  deflecting  the  entering  light 
toward  their  bases  the  prisms  give  to  rays  from  a  certain 
near  point  a  direction  as  if  they  came  from  a  greater  dis- 


340  REFRACTION     AND     ACCOMMODATION. 

tance,  and  thus  lessen  the  need  for  convergence  of  the  optic 
axes  The  prisms  may  be  combined  with  concave  lenses. 
M.  may  also  be  caused  b}^  an  increase  of  the  curvature, 
or  of  the  refractive  power  of  the  media,  myojna  of  curva- 
ture. Thus,  in  conical  cornea  the  curvature  of  the  central 
part  of  the  cornea  is  increased  {i.  e.,  its  focal  length 
shortened),  and  the  principal  focus  of  the  lens  system  lies 
in  front  of  the  retina,  often  very  far  in  front,  without  any 
change  of  place  of  the  parts  at  the  back  of  the  eye.  M., 
usually  of  low  degree,  often  comes  on  in  commencing  senile 
cataract  from  a  shortening  of  the  focal  length  of  the  crystal- 
line lens,  but  whether  this  is  due  to  increase  of  convexity 
or  of  refractive  index  is  uncertain.  M.  is  sometimes  simu- 
lated in  H.,  and  actual  M.  increased,  by  needless  and  un- 
controllable action  of  the  ciliary  muscle. 

Hypermetropta  (H  ). 

H.  is  optically  the  reverse  of  M.  It  is  one  of  the  com- 
monest conditions  we  have  to  treat.  The  eyeball  is  too 
short,  axial  hypermetropia,  so  that  when  the  accommoda- 
tion is  relaxed  the  retina  lies  within  the  principal  focus  of 
the  eye.  As  rays  from  an  object  within  the  principal  focus  of 
a  convex  lens  emerge  from  the  lens  divergent,  so  pencils  of 


Hyperraetropia.     Parallel  rays  focu&sed  behind  retina.     Rays  already 
convergent  focussed  on  retina. 

rays  leaving  a  hypermetropic  eye  are  divergent  (Fig.  115) ; 
and,    conversely,    only    rays   already  convergent  can   V)e 


HY  PERMETROPI  A.  341 

focussed  on  the  retina.  H.  always  dates  from  birth,  and 
does  not  afterwards  increase,  except  slightly  in  old  age.  But 
it  may  diminish  and  even  give  place  to  M.  by  elongation  of 
the  eye.  In  Fig.  Ill  the  curved  line  representing  the  retina 
is  in  front  of  f.  Parallel  rays  will,  after  passing  through 
the  lens,  meet  the  retina  before  focussing  and  form  a  blurred 
image,  whilst  divergent  rays,  meeting  the  retina  still  further 
from  their  focus,  will  form  an  even  worse  image  ;  hence 
neither  distant  nor  near  objects  will  be  seen  clearly.  But 
by  using  accommodation  the  focal  length  can  be  shortened 
until  the  focus  falls  upon  the  retina  (Fig.  112),  and  distant 

Fig.  112. 


Hypermetropia  corrected  by  accommodation.      Parallel  rays  focussed 
on  retina. 

objects  are  then  seen  clearly  ;  and  additional  accommoda- 
tion will  give  also  distinct  vision  of  near  objects.  A  little 
consideration  will  show  that  the  competence  of  the  ciliary 
muscle  to  give  these  results  will  depend  in  any  given  case  : 
(1)  on  the  degree  of  advancement  of  the  retina  in  front  of 
F,  i.  e.,  on  the  degree  of  shortening  of  the  eye;  and  (2)  on 
the  strength  of  Ace,  i.  e.,  on  the  extent  to  which  the  focal 
length  of  the  lens  can  be  altered. 

The  same  result  may  be  gained  by  placing  a  convex 
lens  in  front  of  the  eye,  instead  of  using  the  accommoda- 
tion. In  a  given  case.  Ace.  being  relaxed,  let  the  ray,  Fig. 
ll.S,  on  leaving  the  eve  diverge  from  the  axis,  as  if  it  pro- 
ceeded from  a  point  v.  f.  25  cm.  behind  the  cornea.  If 
the  ray  a',  parallel  with  the  axis,  pass  through  a  convex 


342  REFRACTION     AND     ACCOMMODATION. 

lens,  Z,  of  25  cm.  focal  length  held  close  to  the  eye,  it  will 
be  made  to  converge  toward  this  same  point,  and,  therefore, 

Fig.  113. 


Hypermetropia  corrected  b}'  a  convex  lens  whose  focus  coincides  with 
the  virtual  focus  of  the  retina. 

in  accordance  with  §  12  (p.  31),  will  be  focussed  on  the  re- 
tina at  a. 

Fig.  114  may  be  taken  for  a  section  of  a  very  highly 
hypermetropic   eye,  the  rays   emerging  from  which  are 

Fig.  114. 


Course  of  the  rays  emerging  from  a  hypermetropic  eye. 

divergent.  The  image  formed  on  the  retina  of  a  hyperme- 
tropic eye  is  smaller  than  that  of  the  same  object  placed 
at  the  same  distance  from  a  normal  eye. 

In  old  age  the  refractive  power  of  the  crystalline  lens 
seems  normally  to  diminish,  and,  therefore,  an  eye  origi- 
nally emmetropic  becomes  unable  to  focus  parallel  rays  on 


HYPER  METROPIA.  343 

the  retina  ;  this  condition  causes  slight  acquired  hyper- 
metropia,  and  begins  at  the  age  of  65. 

SyiMptoms  and  Results  of  H. — The  direct  symptoms 
are  due  to  insufficiency  of  the  accommodation  ;  for  distinct 
vision  of  any  object,  whether  near  or  distant,  requires  Ace. 
proportionate  to  the  degree  of  shortening  of  the  eye,  and 
the  absolute  power  (amplitude)  of  Ace.  is  not  increased  in 
H.,  at  any  rate,  not  enough  to  meet  the  demand. 

If  H.  is  slight  or  moderate  and  Ace.  vigorous,  no  incon- 
venience is  felt  either  for  near  or  distant  vision.  But  if 
Ace.  have  been  weakened  by  disease  or  ill-health,  or  have 
failed  with  age,  the  patient  will  complain  that  he  can  no 
longer  see  near  objects  clearly  for  long  together  ;  that  the 
eyes  ache  or  water,  or  that  everything  "  swims"  or  becomes 
"  dim"  after  reading  or  sewing  for  a  short  time,  accommoda- 
tive asthenopia.  There  is  not  usually  much  complaint  of 
defect  for  distant  objects.  Many  slight  or  moderately  H. 
patients  find  no  inconvenience  till  25  or  80  years  of  age, 
when  Ace.  has  naturally  declined  by  nearly  one-half. 

Women  are  often  first  troubled  after  a  long  lactation,  and 
other  persons  after  prolonged  study  or  deskwork,  or  when 
suffering  from  chronic  exhausting  diseases.  Children  often 
complain  of  watering,  blinking,  and  headache,  rather  than 
of  dimness. 

In  very  high  degrees  of  H.,  as  a  large  part  of  Ace.  is 
always  needed  from  childhood  upward  for  distant  sight, 
even  the  strongest  effort  does  not  suffice  to  give  clear  images 
of  near  objects,  which  consequently  such  a  person  never 
sees  well.  Such  patients  often  partly  compensate  for  the 
dimness  of  near  objects  by  bringing  them  still  nearer,  thus 
enlarging  the  visual  angle  and  increasing  the  size  of  the 
retinal  images.  This  symptom  may  be  mistaken  for  M., 
but  can  be  distinguished  by  the  want  of  uniformity  in  the 
distance  at  which  the  patient  places  his  book,  and  by  his 
being  often  unable,  at  any  distance  whatever,  to  see  the  print 


'Ui  REFRACTION     AND     A  C  C  O  M  M  0  D  A  T  J  0  N  . 

easily  or  to  read  fluently.  In  the  highest  degrees  even  dis- 
tinct distant  vision  is  not  constantly  maintained,  the  patient 
often  being  content  to  let  his  accommodation  rest  except 
when  his  attention  is  roused. 

As  age  advances,  a  point  is  reached,  even  in  moderate 
degrees  of  H.,  at  which  Ace.  no  longer  suHices  even  for  dis- 
tant, and  much  less  for  near  vision.  Such  persons  tell  us 
that  they  early  took  to  glasses  for  near  work,  but  add  that 
lately  the  glasses  have  not  suited,  and  that  they  are  now 
unable  to  see  clearly  either  at  long  or  short  distances. 
Ophthalmoscopic  examination  shows  no  change  except  H., 
and  suitable  convex  glasses  at  once  raise  distant  vision  to 
the  normal.  Occasionally  photophobia,  conjunctival  irri- 
tation, and  redness  are  present  in  H.,  but  the  first-named 
symptom  is  less  common  than  in  M. 

The  most  important  indirect  result  of  H.  is  convergent 
strabismus.  To  understand  this  we  must  remember  that 
there  is  a  certain  constant  relation  between  the  action  of 
the  ciliary  muscles  and  of  the  internal  recti, — that  Ace. 
can  be  exerted  only  to  a  very  limited  degree  without  con- 
vergence of  the  optic  axis,  and  that  for  every  degree  of 
Ace.  there  is,  in  the  normal  state,  a  constant  amount  of 
convergence.  In  H.  accurate  near  sight  needs,  as  we  have 
seen,  an  excess  of  Ace,  thus  e.  g.  with  H.  of  2  D.,  clear 
vision  of  an  object  at  50  cm.  will  require  as  much  Ace.  as 
vision  at  25  cm.  by  a  normal  eye,  and  this  Ace.  cannot  be 
exerted  without  converging  for  25  cm.,  or  nearly  so.  Such  a 
person, therefore,  has  to  do  two  things  at  once — to  look  at  an 
object  distant  50  cm.,  and  to  make  his  optic  axes  meet  at  25 
cm.  The  former  he  does  by  directing  one  eye,  e.  g.,  the  R., 
to  the  object  50  cm.  off;  the  latter  by  converging  the  visual 
axes  so  that  the  L.  meets  the  R.  at  25  cm.  instead  of  50 
cm.  In  this  case  the  L.  eye  will  squint  inwards,  hut  both 
internal  recti  will  act  equally  in  bringing  about  the  con- 


HYPER  METROPIA.  345 

vergence,  and  both  eyes  will  use  as  much  Ace.  as  a  pair  of 
normal  eyes  would  do  at  25  cm. 

This  "concomitant"  convergent  strabismus  generally 
comes  on  early  in  childhood,  as  soon  as  the  child  begins  to 
look  attentively  and  use  Ace.  vigorously  in  regarding  near 
objects.  In  examining  cases  we  shall  be  struck  by  finding 
that :  (1)  in  some  the  squint  is  noticed  only  when  Ace.  is 
in  full  use — that  it  appears  and  disappears  under  observa- 
tion, according  as  the  child  fixes  its  gaze  on  a  near  object 
or  looks  into  space  {periodic  squint). 

Periodic  squint  often  occurs,  chiefly  when  the  child  is  nervous 
or  tired ;  several  patients  have  assured  me  that  their  occasional 
convergent  squint  scarcely  ever  came  on  except  when  eating. 

(2)  In  others  the  squint  is  constant,  but  is  more  marked 
during  strong  Ace. ;  (3)  it  is  constant,  invariable,  and  of 
high  degree ;  (4)  in  most  cases  the  squint  always  affects 
the  same  eye,  and  this  is  generally  accounted  for  by  some 
original  defect  of  the  eye  itself,  such  as  a  higher  degree  of 
H.,  or  As.,  or  a  corneal  opacity,  which  leads  to  its  fellow 
being  chosen  for  distinct  sight ;  but  patients  who  see  equally 
well  with  each  eye  often  squint  with  either  indifferently, 
alternating  squint.  The  squint  causes  diplopia,  and  to 
avoid  this  inconvenience  patients  for  the  most  part  soon 
learn  to  ignore,  or  "suppress,"  the  image  formed  in  the 
squinting  eye,  the  result  usually  being  that  this  eye  becomes 
very  defective.  This  power  of  suppressing  the  false  image 
is  learnt  most  easily  in  very  early  life.  In  alternating 
squint  no  permanent  suppression  occurs,  and  consequently 
both  eyes  remain  good. 

It  will  soon  be  noticed  that  squint  is  not  present  in  every 
case  of  H.  In  very  low  degrees  the  necessary  extra  Ace. 
can  often  be  used  without  any  extra  convergence.  In  very 
high  degrees,  on  the  other  hand,  the  effort  needed  for  dis- 
tinct vision,  even  of  distant,  and  a  fortiori  of  near,  objects, 

15* 


346  REFRACTION      AND     ACCOMMODATION. 

is  so  great  that  the  child  often  sacrifices  distinctness  to 
comfort  and  binocular  vision,  using  only  so  much  Ace.  as 
can  be  employed  without  over-convergence.  The  squint 
disappears  sometimes  spontaneously  as  the  child  grows  up; 
this  might  be  explained  by  an  increased  power  of  dissoci- 
ating Ace.  from  convergence,  or  by  a  diminution  of  H. 
from  elongation  of  the  eye,  or  by  a  general  tendency  in  all 
persons,  and  of  this  there  is  other  evidence,  to  weakening 
of  the  internal  recti  with  advancing  age. 

Treatment. — The  treatment  of  H.  consists  in  removing 
the  necessity  for  overuse  of  Ace.  by  prescribing  convex 
spectacles  which,  in  proportion  to  their  strength,  supply 
the  place  of  the  increased  convexity  of  the  crystalline  lens 
Induced  by  Ace.  In  theor}^,  the  whole  Ace.  ought  to  be 
corrected  by  glasses  in  every  case,  and  the  eye  be  rendered 
emmetropic.  But,  in  practice,  we  find  it  often  better  to 
give  a  weaker  glass,  at  least  for  a  time. 

If  Ace.  in  a  H.  eye  be  in  abeyance,  paralyzed  by  atropia, 
vision  for  distant  objects  will  be  distinct  only  if  the  rays 
pass  through  a  convex  lens,  held  in  front  of  the  eye,  whose 
focus  coincides  with  the  virtual  focus  of  the  retina.  The 
strength  of  this  lens  is  the  measure  of  the  H. ;  thus  the 
patient  has  H.  2  D.  if  a  convex  lens  of  50  cm.  focal  length 
is  necessary  for  this  purpose. 

But  if  Ace.  be  intact,  then,  as  it  has  constantly  to  be 
used  for  distant  sight,  the  patient  is  often  unable  to  relax 
it  fully,  when  a  corresponding  convex  lens  is  placed  in  the 
front  of  the  eye ;  he  will  relax  only  a  part,  and  this  part 
will  be  measured  by  the  strongest  convex  lens  with  which 
he  can  see  the  distant  types  clearly.  That  part  of  the  H. 
which  can  be  detected  by  this  test  is  called  "manifest"  (m. 
H.).  The  part  remaining  undetected,  because  corrected  by 
the  involuntary  use  of  Ace  ,  is  latent  (1.  H  ).  The  sum  of 
the  m.  H.  and  1.  H.  is  the  total  H. 

Now,  most  H.  people  can  habitually  use  some  Ace.  for 


HYPER  METROPIA.  347 

distance  fand  a  corresponding  excess  for  near  vision)  with- 
out inconvenience,  and  hence  the  full  correction  of  H.  is 
by  no  means  always  needful,  or  even  agreeable  to  the  pa- 
tient. In  manv  cases  correction  of  the  m.  H.  is  enough 
to  relieve  the  asthenopic  symptoms,  at  any  rate  for  a  con- 
siderable time;  but  we  often  find  that  after  wearing  these 
glasses  for  some  weeks  or  months,  the  symptoms  return,  and 
a  fresh  trial  will  show  a  larger  amount  of  m.  H.,  which 
must  then  again  be  corrected  by  a  corresponding  increase 
in  the  strength  of  the  glasses.  This  process  may  have  to 
be  repeated  several  times  until  after  a  few  months  the  total 
H.  becomes  manifest  and  may  be  corrected.  This  method 
is  most  suitable  for  adults  in  whom  the  use  of  atropine  to 
paralyze  Ace,  and  allow  the  immediate  estimation  of  the 
total  H.,  is  inconvenient  or  impossible  ;  or  for  whom  the 
glasses  which  correct  the  total  H.,  as  estimated  by  the 
ophthalmoscope,  without  atropinization,  are  found,  if 
ordered  at  once,  to  be  inconveniently  strong.  But  for 
children  there  is  seldom  any  gain,  and  often  no  little  in- 
convenience, from  following  this  gradual  plan;  with  them 
the  better  way  is  to  estimate  the  total  H.,  and  to  order 
glasses  slightly  (about  ID.)  weaker  than  that  amount. 

To  Examine  for  H. — (1.)  For  m.  H.  Note  the 
patient's  vision  for  distant  types  at  6  m.,  then  hold  in  front 
of  his  eyes  a  very  weak  convex  lens  (-f  0.5  D.),  and  if  he 
sees  as  well,  or  better,  with  it,  go  to  the  next  stronger  lens, 
and  so  on  until  the  strongest  has  been  found  which  allows 
the  best  attainable  distant  vision;  this  lens  is  the  measure 
of  the  m.  H. 

(2.)  ForH.  (total). — The  easiest  and  most  certain  plan 
is  to  direct  the  patient  to  use  strong  atropine  drops  (F.  31) 
three  times  a  day  for  at  least  two  days,  and  then  to  test  his 
distant  vision  with  convex  glasses.  As  in  (1),  the  strongest 
lens  which  gives  the  best  attainable  sight  is  the  measure  of 
the  H. 


34S  R  E  F  U  A  C  T  1  O  N     AND     A  C  C  O  M  M  O  D  A  T  1  O  N  . 

Ophthalmoscopic  Tests. — (3.)  The  image  of  the  disc 
seen  by  the  indirect  method  becomes  smaller  when  the 
lens  is  withdrawn  from  the  eye. 

(4.)  The  retinoscopic  test  is  described  at  p.  82. 

(5.)  By  direct  examination  an  erect  image  is  seen  at 
whatever  distance  the  observer  be  from  the  patient.  The 
observer  may  learn  to  estimate  H.  with  almost  as  great 
accuracy  with  a  refraction  ophthalmoscope  as  by  trial 
lenses,  and  this  plan,  like  retiuoscopy,  is  extremely  valu- 
able with  children  who  are  too  young  or  too  backward  to 
give  good  answers.  The  total,  or  nearly  the  total,  H.  may 
often  be  found  in  this  way  without  atropine  if  the  exami- 
nation be  made  in  a  dark  room,  for  then  Ace.  is  generally 
quite  relaxed,  however  persistently  it  may  have  acted  when 
the  patient  was  able  to  look  attentively  at  objects  in  the 
light.  The  objective  estimates  (4  and  5),  however,  are 
more  easily  made  after  the  use  of  atropine. 

The  next  question  is,  whether  the  glasses  are  to  be  worn 
always,  or  only  when  Ace.  is  specially  strained,  i.  e.,  in 
near  work.  They  are  to  be  worn  constantly  (1)  whenever 
we  are  attempting  to  cure  a  squint  by  their  means;  (2)  in 
all  cases  of  high  H.  in  children,  whether  with  or  without 
strabismus.  But  patients  who  come  under  care  for  the  first 
time  as  young  adults,  in  whom  the  H.  is,  as  a  rule,  of 
moderate  or  low  degree,  may  generally  be  allowed  to  wear 
them  only  for  near  work.  Elderly  persons  require  two 
pairs — one  for  distance,  neutralizing  the  m.  H.,  the  other 
stronger,  neutralizing  the  presbyopia  also,  for  near  work ; 
the  use  of  the  former  may,  however,  be  left  to  the  patient's 
choice. 

Treatment  of  Convergent  Hypermetropic  Squint. 

(I.)  If  the  squint  be  periodic,   it  can   be  cured  by  the 
constant  use  of  spectacles  which  nearly  correct  total  H. 
(2.)  The  same  is  true  in  some  cases  where  the  squint, 


AST1GMATI8M  349 

though  constant,  varies  in  degree,  being  greater  during  Ace. 
for  near  than  for  distant  objects. 

(3.)  If  the  squint  be  constant  in  amount  and  of  some 
years'  standing,  operation  is  usually  necessary.  As  the 
squinting  eye  is  then  usually  very  defective,  the  removal  of 
the  deformity  is  the  chief  object  of  the  operation,  binocular 
vision  being  comparatively  seldom  restored.  Hence,  in 
view  of  the  tendency  to  spontaneous  cure  already  men- 
tioned, I  think  it  better,  as  a  rule,  not  to  operate  on  chil- 
dren below  the  age  of  six,  especially  as  in  younger  children 
we  cannot  always  tell  whether  or  not  the  squint  be  still 
periodic.  The  most  rational  treatment  for  children  under 
four  (when  glasses  may  often  be  begun),  is  to  cover  the 
eyes  alternately  with  a  blind,  for  some  hours  daily,  to 
insure  each  eye  alter nateh^  used  ;  but  this  plan  can  seldom 
be  carried  out. 

When  operation  is  decided  upon,  it  is  a  safe  rule  to 
divide  only  one  internal  rectus  at  a  sitting.  At  the  end 
of  a  few  weeks,  if  the  squint  still  be  considerable,  the 
operation  is  performed  on  the  other  eye.^ 

Muscular  asthenopia  is  very  likely  to  come  on  some 
years  later,  if  both  tendons  are  needlessly  divided.  It  is 
safer  to  leave  slight  convergence  than  to  run  this  risk. 
(See  also  Divergent  Strabismus.) 

Astigmatism  (As.). 

In  the  preceding  cases  (M.  and  H.)  the  refracting  sur- 
faces of  the  eye  (the  front  of  the  cornea  and  the  two  sur- 
faces of  the  lens)  have  been  regarded  as  segments  of 
spheres. 

All  the   rays  of  a   cone  of   light   which  issue   from   a 

1  Regulations  for  operating  in  convergent  strabismus  in  relation  to  its 
degree  have  been  laid  down  by  various  authors ;  recently  by  Hirseh- 
berg,  Centralbl.  f.  A.,  1886,  p.  5. 


350         REFRACTION     AND     ACCOMMODATION. 

round  spot  and  pass  through  such  a  system  are,  neglecting 
"spherical  aberration,"  equally  refracted,  and  meet  one 
another  at  a  single  point — the  focus  of  the  system.  For  if 
such  a  cone  of  incident  light  be  looked  upon  as  composed 
of  a  number  of  different  planes  of  rays,  situated  radially 
around  the  axis  of  the  cone,  the  rays  situated  in  any  plane, 
say  the  vertical,  will,  after  passing  through  the  lens-system, 
meet  behind  it  at  its  focus,  whilst  those  forming  any  other 
plane,  as  the  horizontal,  will  meet  at  the  same  point ;  and 
the  same  will  be  true  of  all  the  intermediate  planes. 

But  let  the  curvature,  and,  therefore,  the  refractive 
power,  of  one  of  the  media,  for  instance,  the  cornea,  be 
greater  in  one  meridian,  say  the  vertical,  than  in  the  hori- 
zontal, then  the  vertical-plane  rays  will  meet  at  their  focus, 
whilst  the  horizontal-plane  rays  at  the  same  distance,  not 
having  yet  met,  wull,  if  received  on  a  screen,  form  a  hori- 
zontal line  of  light.  If  the  intermediate  meridians  had 
regularly  intermediate  focal  lengths,  they  w^ould  form,  at 
the  same  place,  lines  of  intermediate  lengths,  and  the  image 
of  the  round  spot  of  light,  if  caught  on  a  screen  at  this 
distance,  would  form  a  horizontal  oval.  To  a  retina  receiv- 
ing such  an  image,  the  round  point  of  light  would  appear 
drawn  out  horizontally.  Such  an  eye  is  called  astigmatic, 
because  unable  to  see  a  point  as  such,  all  round  points  ap- 
pearing drawn  out  more  or  less  into  lines. 

A  little  reflection  will  show  that  in  the  same  case,  at  the 
focal  point  of  the  horizontal-plane  rays,  the  rays  of  the 
vertical  plane  will  already  have  met  and  crossed,  and  that 
the  image  at  this  point  will  form  a  vertical  oval. 

If  the  screen  be  placed  midway  between  these  two  ex- 
treme points,  the  image  will  be  circular,  but  blurred,  be- 
cause the  vertical-plane  rays  will  have  crossed,  and  begun  to 
separate,  while  the  horizontal  ones  will  not  yet  have  met, 
and  each  set  will  be  equally  distant  from  its  focus.  The 
meridians  of  the  astigmatic  medium  which  refract  most, 


ASTIGMATISM. 


851 


shortest  focus,  and  least,  longest  focus,  are  the  principal 
meridians.  The  distance  between  their  foci  is  the  focal 
interval,  and  represents  the  degree  of  astigmatism. 

The  astigmatism  of  the  ere  may  be  regular  or  irregular. 
In  regular  astigmatism,  the  meridians  of  greatest  and  least 
refractive  power,  "principal  meridians,"  are  always  at 
right  angles  to  each  other ;  and  every  meridian  is  nearly  a 
segment  of  a  circle.  Of  the  principal  meridians  the  most 
refractive,  the  one  with  shortest  focal  length,  is,  as  a  rule, 
vertical,  or  nearly  so,  and  the  least  refractive,  therefore, 
horizontal,  or  nearly  so.  The  cornea  is  the  principal  seat 
of  this  asymmetry.  The  crystalline  lens,  however,  is  also 
astigmatic,  to  a  less  degree,  and  its  m,eridians  of  greatest 
and  least  curvature  are  usually  so  arranged  as  in  some  de- 
gree to  neutralize  those  of  the  cornea  ;  it  thus  partially 
corrects  the  corneal  error.  Corneal  astigmatism  is  often 
caused  by  operations  for  cataract  or  iridectomy. 

Fig.  115. 


Course  of  rays  passing  through  the  two  "principal  meridians"  of 
a  cylindrical  lens. 


Regular  astigmatism  is  corrected  by  a  lens  which  equal- 
izes the  refraction  in  the  two  principal  meridians.  Such  a 
lens,  Fig.  1 15,  must  be  a  segment  of  a  cylinder,  instead  of, 


352  REFRACTION     AND     ACCOMMODATION. 

like  an  ordinar}'  lens,  a  segment  of  a  sphere.  Ra3^s  trav- 
ersing a  cylindrical  lens  in  the  plane  of  the  axis  of  the 
cylinder  are  not  refracted,  since  the  surfaces  of  lens  in 
this  direction  are  parallel ;  but  rays  traversing  it  in  all 
other  planes  are  refracted  more  or  less,  and  most  in  the 
plane  or  meridian  at  a  right  angle  with  the  axis. 

Irregular  astigmatism  may  be  caused  either  by  irreg- 
ularities of  the  cornea,  arising  from  ulceration,  inflamma- 
tion, or  conicity  ;  ^  or  by  various  conditions  of  the  crystal- 
line lens,  such  as  differences  of  refraction  in  its  various 
sectors,  tilting  or  lateral  dislocation  of  the  lens,  so  that  its 
axis  no  longer  corresponds,  as  it  should  nearly  do,  with  the 
centre  of  the  cornea.  Irregular  astigmatism  causes  much 
distortion  of  the  ophthalmoscopic  image,  especially  when 
the  object  lens  is  moved  from  side  to  side.  It  is  seldom 
much  benefited  by  glasses. 

Returning  to  Begular  Astigmatism,  it  wnll  be  seen  that 
the  optical  condition  of  the  eye  depends  upon  the  position 

Fig. 116. 


of  the  retina  in  respect  to  focal  interval.  In  the  above 
diagram.  Fig.  116,  let  the  most  refractive  meridian  be 
vertical  and  its  focus  be  called  a,  the  least  refracting  meri- 
dian horizontal  and  its  focus  h.     The  astigmatism  is  here 

*  There  can  be  little  doubt  from  clinical  observation  with  a  refraction 
ophthalmoscope,  that  corneal  As.  is  often  complicated  by  the  curvature 
of  each  meridian  being  naturally  more  or  less  elliptical  instead  of  cir- 
cular, and  this  without  any  tendency  toward  "conical  cornea,"  as 
commonly  understood. 


ASTIGMATISM.  353 

represented  as  caused  by  altered  position  of  the  retina  in 
different  plsines  instead  of  hyahered  curvature  of  the  cornea 
in  different  planes,  the  diagram  being,  of  course,  only  in- 
tended to  aid  the  comprehension  of  the  principle.  (1)  Let 
a  fall  on  the  retina,  1,  Fig.  llfi,  and  b,  therefore,  behind 
it.  There  is  E.  in  the  vertical  meridian,  and  therefore  H. 
in  the  horizontal  meridian  ;  this  is  simple  H.  As.  (2)  Let 
b  fall  on  the  retina,  2,  Fig.  116,  and  a  in  front  of  it.  The 
horizontal  meridian  is,  therefore,  E.,  and  the  vertical  meri- 
dian M. ;  simple  M.  As.  (3)  Let  a  and  b  both  lie  behind 
the  retina,  3,  Fig.  116.  There  is  H  in  both  meridians, 
but  more  in  the  horizontal  than  the  vertical  meridian  ; 
compound  H.  As.  (4)  a  and  b  are  both  in  front  of  the 
retina,  4,  Fig.  116.  There  is  M.  in  both  meridians,  but 
more  in  the  vertical  than  the  horizontal :  compound  M.  As. 
(5)  a  as  in  front  of  the  retina,  and  b  behind  it,  5,  Fig.  116. 
There  is  M.  in  the  vertical  and  H.  in  the  horizontal  meri- 
dian ;  mixed  As. 

The  general  symptoms  of  As.  resemble  those  caused  by 
the  simpler  defects  of  refraction  ;  but  attention  to  the  pa- 
tient's complaints  and  to  the  manner  in  which  he  uses  his 
eyes,  will,  in  the  higher  degrees,  often  give  the  clue  to  its 
presence.  Low  degrees,  especially  of  simple  H.  As.,  often 
give  rise  to  no  inconvenience  till  rather  late  in  life.  As.  is 
most  commonly  met  with  in  connection  with  H.,  because 
H.  is  so  much  commoner  than  M.  But  it  is  said  to  occur 
with  greater  relative  frequency  in  M.,  when,  if  complica- 
tions be  present,  it  may,  if  not  of  high  degree,  be  readily 
overlooked,  unless  specially  sought  for.  The  higher  grades 
of  As.  cause  much  inconvenience,  no  objects  being  seen 
clearly  ;  and  spherical  glasses,  though  of  use  if  the  As.  be 
compound,  are  nearly  useless  if  it  be  simple.  As.  is  always 
to  be  suspected  if,  with  the  best  attainable  spherical  glasses, 
distant  vision  is  less  improved  than  it  ought  to  be,  sup- 
posing, of  course,  that  no  other  changes  are  present  to 


354 


REFRACTION     AND     ACCOMMODATION. 


account  for  the  defect.  No  definite  rule  can  be  laid  down 
as  to  the  degree  of  defect  which  should  raise  the  suspicion 
of  As.  ;  indeed,  in  the  higher  degrees  of  even  simple  M. 
and  H  ,  acuteness  of  vision  is  often  below  normal.  There 
seems  no  doubt  that  in  young  persons  with  vigorous  accom- 
modation the  astigmatism  of  the  cornea  is  often  partly 
corrected  by  the  ciliary  muscle  acting  unequally  on  the 
different  meridians  of  the  lens;  and  that  the  seemingly 
greater  frequency  of  astigmatism  in  the  presbyopic  is  due 
to  the  impairment  of  this  power. 


Fig.  117. 


Fig.  118. 


Erect  image  of  disc  in  Astigmatism  The  same  disc,  seen  by  the 

with  meridian  of   greatest  refraction      indirect   method.      (Wecker 
nearly  vertical.  (Wecker  and  Jaeger.)       and  Jaeger.) 

As.  may  be  measured  either  by  trial  with  glasses,  by 
retinoscopy,  or  by  ophthalmoscopic  estimation  of  the  refrac- 
tion of  the  retinal  vessels  in  the  two  chief  meridians.  A 
comparatively  easy  qualitative  test  is  found  in  the  apparent 
shape  of  the  disc,  which,  instead  of  being  round,  is  more 
or  less  oval.  In  the  erect  image  the  long  axis  of  the  oval 
corresponds  to  the  meridian  of  greatest  refraction,  and  is, 
therefore,  as  a  rule,  nearlv  vertical.     Fig.  117. 


ASTIGMATISM.  355 

In  the  inverted  image,  Fig.  118,  the  direction  of  the 
oval  is  at  right  angles  to  the  above,  provided  that  the 
object  lens  be  nearer  than  its  own  focal  length  to  the  eye. 
As.  is  suspected  when,  in  the  erect  image,  an  undulating 
retinal  vessel  appears  clear  in  some  parts  and  indistinct  in 
others,  an  appearance  which  may  be  taken  for  retinitis  if 
the  examination  be  confined  to  the  erect  image.  It  may 
be  imitated  by  looking  at  a  wavy  line  through  a  cylindri- 
cal lens. 

In  the  indirect  examination  the  shape  of  the  disc  changes 
on  withdrawing  the  lens  from  the  patient's  eye.  It  will  be 
remembered  that  in  M.  the  image  increases  as  the  lens  is 
withdrawn  ;  that  in  E.  its  size  remains  the  same,  whilst  in 
H.  it  diminishes,  Fig.  108.  Thus,  in  a  case  of  simple  M. 
As.  in  the  vertical  meridian,  that  dimension  of  the  disc 
which  is  seen  through  the  vertical  meridian  will  enlarge 
on  distancing  the  lens;  from  being  oval  horizontally  when 
the  lens  is  close  to  the  eye,  it  becomes  first  round  and  then 
oval  vertically  on  withdrawing  the  lens.  In  the  other 
forms  of  As.  the  same  holds  true ;  the  image  enlarges 
either  absolutely,  as  in  M.  As.,  or  relatively,  as  in  H.  As., 
in  the  direction  of  the  most  refracting  meridian. 

The  subjective  tests  for  As.  are  very  numerous,  but  all 
depend  on  the  fact,  that  if  an  astigmatic  eye  look  at  a 
number  of  lines  drawn  in  different  directions,  some  will  be 
seen  more  clearly  than  others.  The  form  of  this  test  is  not 
a  matter  of  great  consequence,  provided  that  the  lines  are 
clear,  not  too  fine,  and  are  easily  visible  with  about  half  the 
normal  Y.  at  from  3  m.  to  6  m.  The  forms  resembling  a 
clock-face  with  bold  Roman  figures  at  the  ends  of  the  radii 
are  very  convenient,  and  I  prefer  the  pattern  recommended 
by  Mr.  Brudenell  Carter  (see  Appendix)  to  any  other  that 
I  have  used.  On  this  face  are  three  parallel  black  lines 
separated  by  equally  wide  white  spaces,  and  which  collec- 


356         REFRACTION     AND     ACCOxMMODATION. 

lively  form  a  "hand"  that  can  be  turned  round  into  the 
positions  of  best  and  worst  vision. 

The  easiest  case  for  estimation  is  one  of  simple  H.  As., 
in  which  the  eye  is  under  atropine.  Many  cases  of  simple 
M.  As.  are  almost  as  easy  to  test.  In  a  given  case  let  the 
eye  be  E.  in  the  vertical  meridian,  and  H.  in  the  hori- 
zontal. With  Ace.  paralyzed,  rays  refracted  by  the  vertical 
meridian  will  be  accurately  focussed  on  the  retina,  whilst 
the  focus  of  those  refracted  b}'  the  horizontal  meridian  will 
be  behind  the  retina,  Fig.  116,  1,  and  consequently  form 
on  it  a  blurred  image.  Now,  the  rays  which  strike  in  the 
plane  of  the  vertical  meridian  are  those  which  come  from 
the  borders  of  horizontal  lines ;  hence  the  patient  under 
consideration  will  see  the  lines  at  a  distance  of  3  ni.  to  6  m. 
quite  clearly  when  the  "  hand"  is  horizontal,  except  their 
ends,  which  will  be  blurred.  The  rays  which  strike  in  the 
plane  of  the  horizontal  meridian  are  those  which  proceed 
from  the  sides  of  vertical  lines,  and  as  this  meridian  is 
hypermetropic,  the  lines  in  the  "  hand,"  when  placed  ver- 
tically, will  be  indistinct,  except  their  ends,  which  will  be 
sharply  defined.  We  now  leave  the  "  hand"  vertical,  and 
test  the  refraction  for  the  lines  in  this  position,  i.  e.,  for  the 
horizontal  meridian,  in  the  ordinary  way,  and  find,  e.g., 
that  with  -f-  2  D.  they  are  seen  most  clearly,  though  not 
perfectly.  On  substituting  for  the  spherical  glass,  -j-  2  D. 
cylinder  with  its  curvature  horizontal,  i.  e.,  its  axis  vertical, 
the  lines  of  the  hand  and  all  the  figures  on  the  clock  will 
be  seen  perfectly ;  the  vertical  lines  and  figures  will  be  seen 
through  the  horizontal  meridian,  corrected  by  the  cylinder 
lens,  and  the  horizontal  figures  through  the  unaided  verti- 
cal meridian,  the  rays  which  pass  through  the  cylinder  in 
this  meridian  not  being  refracted. 

In  a  case  of  simple  M.  As.  in  the  vertical  meridian  the 
lines  of  the  "  hand  "  will  be  dull  or  invisible  when  hori- 
zontal, whilst  when  vertical  they  will  be  clear      On  trial  a 


ASTIGMATISM.  35T 

concave  cylinder  will  be  found,  which,  with  its  curvature 
vertical,  axis  horizontal,  makes  the  lines  of  the  hand  quite 
clear  when  horizontal,  and  all  the  figures  quite  plain. 

The  cases  of  compound  and  mixed  As.  are  less  easily 
dealt  with  by  this  test.  It  is  generally  best  to  find,  in  the 
usual  way,  the  spherical  glass  which  gives  the  best  result 
for  the  distant  types,  and  then,  arming  the  eye  with  this 
glass,  to  test  for  As.,  with  the  clock-face  and  cylindrical 
lenses,  as  in  the  simple  cases  described  above. 

We  may  use,  instead  of  a  cylindrical  glass,  a  narrow  slit 
in  a  round  plate  of  metal,  which  can  be  placed  in  the  direc- 
tion of  either  of  the  chief  meridians,  the  spherical  glass 
being  then  found  with  which,  in  each  meridian,  the  patient 
sees  best.  One  chief  meridian  may  be  ascertained  by  finding 
the  direction  of  the  slit  which  gives  the  best  sight  with  the 
spherical  glass  chosen  in  the  preliminary  examination,  and 
the  other  meridian  by  finding  the  glass  which  gives  the  best 
result  with  the  slit  at  a  right  angle  to  the  former  direction. 

Another  method,  that  of  Javal,  consists  in  making  the 
patient  highly  myopic  for  the  time  being,  by  means  of  a 
convex  lens  (unless  he  be  myopic  already);  then  accurately 
finding  his  far  point  for  the  least  myopic  meridian,  and, 
lastly,  finding  the  concave  cylinder  which  is  needed  to 
reduce  the  opposite  meridian  to  the  same  refraction.  A 
special  apparatus  is  needed. 

Ophthalmoscopic  estimation  and  retinoscopy,  however, 
save  much  time,  especially  in  mixed  As.  If  As.  be  meas- 
ured by  direct  ophthalmoscopic  examination,  we  may  re- 
member that  the  axis  of  the  correcting  cylinder  will  be 
parallel  to  the  vessel  used  as  a  guide  to  either  of  the  chief 
meridians ;  and  that  in  retinoscopy  the  same  axis  is  parallel 
to  the  edge  of  the  shadow.  Thus,  if  a  vertical  vessel  be 
clearly  seen  with  +  2  D.,  the  horizontal  vessels  being  best 
seen  with  no  lens,  retinoscopy  will  also  show  H.  2  D.  for 
the  shadow  moving  horizontally,  i.e.,  with  a  vertical  edge, 


358         REFRACTION     AND     ACCOMMODATION. 

and  the  patient  will  choose  a  cylinder  of  -f  2  D.  with  the 
axis  vertical,  i.  e.,  its  curvature  horizontal  because  the 
horizontal  meridian  of  his  eye  has  H.  2D.,  the  vertical 
meridian  being  E. 

Whatever  means  be  employed  the  degree  of  As.  is  ex- 
pressed by  the  difference  between  the  glasses  chosen  for  the 
two  chief  meridians;  or  by  the  cylindrical  lens  which, 
added  to  the  chosen  spherical,  gives  the  best  result  for  the 
lines  or  the  distant  types.  When  cylindrical  glasses  are 
ordered  the  whole  of  the  astigmatism  should  be  corrected. 
It  is  not  usually  necessary  to  correct  astigmatism  of  less 
than  1  D.  ;  but  exceptions  to  this  rale  are  not  uncommon, 
some  patients  deriving  marked  relief  from  the  correction 
of  lower  grades. 

Vision  is  often  defective  in  As.,  and  in  the  high  degrees 
we  are  often  obliged  to  be  content  with  a  very  moderate 
improvement  at  the  time  of  examination.  This  may  some- 
times be  explained  by  the  retina  never  having  received 
clear  images,  i.  e.,  never  having  been  accurately  practised  ; 
y.  in  such  cases  often  improves  after  proper  glasses  have 
been  worn  for  some  months.  In  other  cases  regular  As. 
is  the  cause  of  the  defect.  Much  also  depends  on  the  intel- 
ligence of  the  patient ;  some  persons  are  far  more  apprecia- 
tive of  slight  changes  in  the  power,  or  in  the  direction  of 
the  axis,  of  the  cylinder  than  others,  and  this  apart  from 
the  absolute  acuteness  of  sight. 

Unequal  refraction  in  the  two  eyes  (An-iso-metropia.) 
— It  is  common  to  find  that  one  eye  has  more  H.,  more  M., 
or  more  As  than  its  fellow  ;  or  that  one  is  normal,  while 
the  other  is  ametropic.  When  the  difference  is  not  more 
than  is  represented  by  1.5  D.,  and  Y.  is  good  in  both,  the 
refraction  may  with  advantage  be  equalized  by  giving  the 
glasses  which  correct  each  eye,  and  the  development  of 
divergent  squint  may  sometimes  be  prevented  by  the  in- 
creased stimulus   to  binocular   vision    thus    given.     But 


ASTIGMATISM.  359 

equalization  is  seldom  possible  if  the  difference  be  greater, 
though,  especially  in  myopic  cases,  advantage  is  sometimes 
gained  by  partial  equalization.  On  the  other  hand,  some 
patients,  probably  those  who  do  not  possess  binocular  vision, 
will  not  permit  even  a  partial  equalization.  When  no  at- 
tempt is  made  to  harmonize  the  eyes,  the  spectacles  ordered 
should  suit  the  less  ametropic  eye.  O'ften,  when  one  eye  is 
E.  and  the  other  M.,  each  is  used  separately  for  different 
distances,  and  both  remain  perfect ;  but  if  one  be  As.  or 
very  H.  it  is  generally  defective  from  want  of  use. 

Contrary  to  what  might  be  expected,  anisometropia  is  seldom, 
if  ever,  corrected  b}-  unequal  action  of  the  two  ciliary  muscles. 

Presbyopia  (Pr.). 

Presbyopia,  old  sight,  often  called  "long  sight,"  is  the 
result  of  the  gradual  recession  ofp,  which  takes  place  as  life 
advances,  and  which  causes  curtailment  of  the  range  or 
amplitude  of  Ace.  From  the  age  of  ten,  or  earlier,  on- 
ward, p  is  constantly  receding  from  the  eye.  When  it  has 
reached  9^'  (22  cm.),  i.  e.,  when  clear  vision  is  no  longer 
possible  at  a  shorter  distance  than  22  cm.,  Pr.  is  said  to 
have  begun.  The  standard  is  arbitrary,  22  cm.  having 
been  fixed  by  general  agreement  as  the  point  beyond  which 
p  cannot  be  removed  without  some  inconvenience,  the  point 
where  age  begins  to  tell  on  the  practical  efficiency  of  the 
eyes  unless  glasses  are  worn.  In  the  normal  eye  this  point 
is  reached  soon  after  forty,  and  the  rate  of  diminution  is  so 
uniform  that  the  glasses  required  to  bring  p  to  22  cm.  may 
often,  if  necessary,  be  determined  merely  from  the  patient's 
age.  But,  as  there  are  exceptions  to  this  rule,  even  for 
normal  eyes,  and  as  allowance  has  to  be  made  for  any  error 
of  refraction  (H.  or  M.),  it  is  unsafe  in  practice  to  rely 
upon  age  except  as  a  general  guide. 

The   slow  failure  of  Ace,   causing  Pr.,  depends  upon 


360         REFRACTION     AND     ACCOMMODATION. 

senile  changes  in  the  lens,  which  render  it  firmer  and  less 
elastic,  and  therefore  less  responsive  to  the  action  of  the 
ciliary  muscle.  There  can  be  little  doubt,  however,  that 
failure  of  the  ciliary  muscle  itself,  or  of  its  motor  nerves, 
also  forms  an  important  factor  in  those  cases  (and  they  are 
well  known)  where  Pr.  comes  on  earlier  or  more  quickly 
than  usual ;  but  it  is  a  curious  fact  that  in  these  cases  of 
premature  Pr.  the  mobility  of  the  iris  is  not  affected. 

As  Pr.  depends  on  a  natural  recession  of  the  near  point, 
it  occurs  in  all  eyes,  whether  their  refraction  be  E.,  M.,  or 
H.  In  M.,  however,  Pr.  sets  in  later  than  in  a  normal  eye, 
because  for  the  same  ravge  of  Ace.  the  r^egion  is  always 
nearer  than  in  the  normal  eye.  In  H.,  on  the  contrary, 
Pr.  is  reached  sooner  than  is  normal,  because  for  the  same 
range  of  Ace.  the  region  is  always  further  than  in  the  normal 
eye.  Thus,  in  an  E.  eye  a  power  of  Ace.  =  4.5  D.  gives 
a  range  from  r  =  infinity  to  j)  =.  22  cm.,  the  focal  length 
of  4.5  D.,  i  e.,  Pr.  is  just  about  to  begin;  at  fet.  50,  Ace. 
=  2.5  D.,  and  p  =  40  cm.  (the  focal  length  of  2.5  D.). 
In  a  case  of  M.  3  D.,  aet.  50,  the  range  being  =  2.5  D.,  the 
region  of  Ace.  lies  between  33  cm.  (the  r  for  this  eye)  and 
18  cm  (=  focal  length  of  3  -f-  2  5  or  5.5  D.) ;  Pr.  has  not 
yet  begun.  In  a  case  of  H.  3  D.  with  4.5  D.  of  Ace,  3  D. 
of  it  are  used  in  correcting  the  H.,  i.  e.,  in  bringing  /-  to 
infinity,  and  only  1.5  D.  remains;  p  is  therefore  at  66  cm. 
(:=  focal  length  of  4.5  —  3,  or  1.5  D.),  and  a  -{-  lens  of 
3  D.  is  needed  to  bring  p  to  22  cm. ;  there  is  Pr.  =  3  D. 
The  only  cases  in  which  Pr.  cannot  occur  are  in  M.  of  more 
than  4.5  D.  Thus  if  M.  =  1  D.,  r  is  at  14  cm.,  and  though, 
with  advancing  years,  jo  will  recede  to  14  cm.,  it  cannot  go 
further,  cannot  reach  22  cm. ;  the  patient,  who  never  could 
see  at  a  greater  distance  than  14  cm.,  has  simply  lost  the 
power  to  see  at  a  shorter  distance.  Fig.  119  shows  these 
facts  in  a  graphic  manner. 


PRESBYOPIA. 


361 


Treatment. — Convex  spectacles  are  found,  by  the  aid 
of  the  Table  at  p.  362,  with  which  the  patient  can  read  at 
22  cm. 

In  practice  it  is  always  proper  to  examine  for  H.  orM., 
by  taking  the  distant  vision,  and  trying  the  patient  for 


Fig.  lift. 


iBBgg^^fi'a'ggiggirg^!^ 

gKNBtMel'H 

Acc=12D.                  J«                                    J 

M.3D.aet1S                            !             •" 
Acc=120.                     L-,.I-----L 
H.3D.aetJ5.  "T  ^                                          1 
Acc^12D.        1                     „,...  ,...-L..-. 

B  L  ^-a  ■ 

Regiou  and  rauge  ot  Ace.  iu  E.,  M..  aud  H. 


E;aet40 
Acct4-5  D. 
E.aet.50. 
Acc=2-5D.    . 
M.3D.3efc.5Q 
Accr2-5D.        1     1 

[-- 

_ 

— 

H.3D.aet.40.  "      [ 
Accf4-5D. 

- 

H 

-j 
-■ 

■  ■ 

"■1 

" 

■B 

Range  of  Ace.  diminishes  wiih  age. 

The  numbers  along  the  top  show  the  range  of  Ace.  in  Dioptres  from 
infinity  (oo  )  (or  beyond  it  in  H.)  to  15  D.  The  numbers  beyond  a 
represent  Dioptres  of  Ace.  necessary  to  correct  H.  Observe  that  the 
rayige  of  Ace.  is  always  the  same  at  the  same  age,  though  its  region 
varies  with  the  refraotion  of  the  eye. 


m.  H.  and  M.  If  m.  H.  be  found,  arm  the  patient  with 
the  glass  which  neutralizes  it  and  makes  him  E.,  and  then 
add  the  convex  glass  that  should,  by  the  Table,  be  required 

16 


362 


REFRACTION     AND     ACCOMMODATION 


to  bring  p  to  22  cm.     If  M.  be  found,  subtract  its  amount 
from  the  corresponding  convex  glass. 

In  prescribing  for  Pr.  we  must  often  order  rather  less 
than  the  full  correction.  For  instance,  if  Ace.  be  almost 
entirely  lost,  p  is  practically  removed  to  r,  and  the  glass 
which  will  bring  p  to  22  cm.  will  also  bring  r  to  the  same, 
or  nearly  the  same  point,  and  the  patient  will  be  able  to  see 
clearly  only  just  there.  Now,  22  cm.  is  too  near  for  sustained 
vision,  and  such  patients  often  prefer  a  glass  which  gives 
them  a  near  point  of  from  30  to  40  cm.  {\2"  to  16'')» 
though  in  choosing  it  they  sacrifice  the  powder  of  easily 
reading  very  small  print.  The  difficulty  experienced  by 
these  patients  in  reading  with  glasses  which  give  p  =  22 
cm,  depends  on  the  unaccustomed  strain  thereby  thrown 
on  the  internal  recti ;  and  it  may  be  removed  or  lessened 
by  adding  to  the  convex  glasses,  prisms,  with  their  bases 
tow^ard  the  nose ;  or  by  decentering  the  ordinary  convex 
lenses  inward. 

Presbyopia  Table  for  Emmetropic  Eyes. 


Distance  of 

Pr.  expressed  by  the  lens  necessary 

P- 

to  bring  p  to  22  cm.  or  9". 

Age. 

Cra. 

Inches. 

Dioptres. 

Paris  inch 
scale. 

40 

22 

9 

0 

0 

45 

28 

11 

+1 

•  +5V 

50 

43 

17 

2 

tV 

55 

67 

27 

3 

tV 

60 

200 

72 

4 

h 

65 

infinity 

4.5 

i 

70 

acquired  H.  =  1     D. 

5.5 

hA 

T5 

1.5  D. 

6 

h 

80 

ii         11 

2.5  D. 

7 

i 

CHAPTER    XXI. 

STRABISMUS  AND  OCrLAR  PARALYSIS. 

Strabismus  exists  whenever  the  two  eyes  are  not,  as 
they  ought  to  be,  directed  toward  the  same  object.  The  eye 
is  "directed  toward"  an  object  when  the  image  is  formed 
on  the  most  sensitive  part  of  the  retina,  the  yellow  spot ; 
the  straight  line  joining  the  centre  of  this  image  with  the 
centre  of  the  object  is  the  "  visual  axis."  The  action  of  the 
ocular  muscles  is  normally  such  as  to  keep  both  visual  lines 
always  directed  to  the  object  under  regard,  binocular  but 
single  vision  being  the  result.  Although  each  eye  receives 
its  own  image,  only  one  object  is  perceived  by  the  senso- 
rium,  because  the  images  are  formed  on  parts  of  the  retinae 
which  "correspond"  or  are  "identical"  in  function,  i.  e., 
which  are  so  placed  that  they  always  receive  identical  and 
simultaneous  stimuli. 

But  if,  owing  to  the  faulty  action  of  one  or  more  of  the 
muscles,  one  eye  deviate,  and  the  visual  lines  cease  to  be 
directed  toward  the  same  object,  the  image  will  no  longer 
be  formed  on  the  y.  s.  in  both  eyes.  In  one  of  them  it 
must  fall  on  some  other  and  non-identical  part  of  the  retina, 
and  the  result  is  that  two  images  of  the  same  object  are 
seen.  In  Fig.  120,  y  is  the  y.  s.  in  each  eye,  and  the  visual 
line  of  the  R.  eye  (the  thick-dotted  line)  deviates  inward ; 
hence  the  image  of  the  object  {ob)  which  is  formed  at  y  in 
the  L.  eye,  will  in  the  R.  eye  fall  on  a  non-identical  part  to 
the  inner  side  of  y.  Ob  will  be  seen  in  its  true  position 
by  the  L.  eye ;  to  the  R.  eye,  however,  it  will  appear  to  be 
at  i^.  ob,  because  the  part  of  the  R.  retina  which  now 


364       STRABISMUS     AND     OCULAR     PARALYSIS. 

receives  the  image  of  06  was  accustomed,  when  the  eye  was 
normally  directed,  to  receive  images  from  objects  in  the 
position  of  F.  oh;  and  in  consequence  of  this  early  habit 

Fm.  120. 


Shows  the  position  of  the  double  images  in  diplopia  from  con- 
vergent or  crossed  strabismus.  The  images  are  homonymous,  or  corre- 
spond in  position  to  the  eyes. 

F.  oh  is  the  position  to  which  every  image  formed  on  this 
part  of  the  retina  is  referred. 

Hence,  if  the  eye  deviate  toward  its  fellow,  convergent 
squint,  as  in  Fig.  120,  the  false  image  will  seem  to  the 
squinting  eye  to  be  in  the  opposite  direction ;  the  image 
{F.  oh)  for  the  R.  eye  being  referred  to  the  patient's  R., 
and  that  for  the  L.  eye  {oh)  to  his  L.  ;  in  convergent  or 
crossed  strabismus  the  double  images  correspond  in  position 


STRABISMUS     AND     OCULAR     PARALYSIS.      365 

to  the  eyes,  or  are  JwmoJiymous.  Similar  reasoning  will 
show  that  if  the  eye  deviate  away  from  its  fellow  (Fig.  121, 
divergent  squint),  the  position  of  the  double  images  must 

Fig. 121. 


Position  of  double  images  in  divergent  strabismus.     The  images 
are  crossed. 


be  reversed,  and  the  image  belonging  to  the  R.  eye  appear 
to  be  to  the  left  of  the  other ;  hence,  in  divergent  squint, 
the  double  images  are  crossed. 

Since  the  image  of  06  in  the  squinting  (K.)  eye  is  formed 
on  a  portion  of  the  retina  more  or  less  distant  from  the 
most  perfect  part  (the  y.  s.),  it  will  not  appear  so  clear  or 
so  bright  as  the  image  formed  at  the  y.  s.  of  the  sound  (or 
"working")  eye;  it  is  called  the  "false"  image,  that 
formed  in  the  working  eye  being  the  "  true"  one.     The 


366       STRABISMUS     AND     OCULAR    PARALYSIS. 

greater  the  deviation  of  the  visual  line  {i.  e.,  the  greater 
the  squint),  the  wider  apart  will  the  two  images  appear, 
and  the  less  distinct  will  the  "  false"  image  be. 

[The  y.  s.  {y)  of  the  squinting  (R.)  eye  will  receive  an 
image  of  some  different  object  lying  in  its  visual  line  (shown 
by  the  thick-dotted  line) ;  this  image,  if  sufficiently  marked 
to  attract  attention,  will  be  seen,  and  will  appear  to  lie 
upon  the  image  of  oh  seen  by  the  '*  working"  (L.)  eye, 
two  equally  clear  objects  will  be  seen  superimposed.  But, 
as  a  rule,  only  one  of  these  images  is  attended  to,  the  per- 
ception of  the  other  being  habitually  suppressed,  even 
sooner  than  that  of  the  "false  image";  the  suppressed 
image  always  belonging  to  the  squinting  eye.] 

Squinting  is  not  always  accompanied  by  double  vision, 
because — (1)  if  the  deviation  be  extreme,  the  false  image 
is  formed  on  a  very  peripheral  part  of  the  retina,  and  is  so 
dim  as  not  to  be  noticed  ;  conversely,  the  less  the  squint 
the  more  troublesome  is  the  diplopia,  when  present ;  (2) 
after  a  time  the  "  false  image"  is  suppressed ;  or  the  eye 
may  have  been  very  defective  before  the  squint  came  on. 

For  the  method  of  examining  for  strabismus  and 
diplopia,  see  pp.  57  and  60. 

Strabismus  may  arise  from  any  one  of  the  following 
muscular  conditions :  (1)  over-action;  (2)  weakness  fol- 
lowing over-use ;  (3)  disuse  of  an  eye  whose  sight  is 
imperfect ;  (4)  stretching  and  weakening  of  a  tendon  after 
tenotomy ;  (5)  paralysis  of  one  or  more  of  the  muscles. 

Fuchs'  has  lately  shown  that  considerable  variations  occur 
in  the  attachments  of  the  recti  and  obliqui  to  the  sclerotic. 
Such  variations  in  the  attachment  and  power  of  the  muscles 
probably  operate  as  predisposing  causes  of  the  squint  in  groups 
1,  2,  and  3. 

1  Fuchs,  Graefe's  Arch.,  xxx.,  abstracted  in  Ophth.  Review,  vol.  iv. 
U3,  1885. 


STRABISMUS     AND     OCULAR     PARALYSIS.      367 

(1.)  Over-action  of  the  internal  recti  gives  rise  to  the 
convergent  squint  of  hypermetropia  (p.  344).  Occasionally- 
convergent  squint  occurs  in  myopia.  Both  forms  are  con- 
comitant (p.  58),  but  in  cases  of  long  standiugthe  range 
of  movement  of  the  squinting  eye  is  often  deficient. 

(2.)  Strabismus  from  weakness  is  always  divergent,  de- 
pending upon  relaxation,  or  absolute  weakening,  of  the 
internal  recti.  It  is  commonest  in  M.,  but  is  not  infrequent 
in  H.,  and  even  in  E.  This  form  of  squint  sets  in  gradu- 
ally, with  difficulty  in  using  the  eyes  for  long  together  for 
reading,  etc.,  the  internal  recti  not  being  able  to  keep  up 
convergence;  in  this  stage  it  may  often  be  detected  by 
covering  one  eye  whilst  the  patient  looks  attentively  at 
some  near  object,  for  the  covered  eye  will  diverge  when 
thus  excluded,  latent  dioergent  squint,  though  in  the  in- 
terest of  binocular  vision  convergence  may  be  maintained  for 
a  short  time  when  both  eyes  are  open.  Latent  divergent 
strabismus  is  sometimes  a  temporary  condition  due  to  over- 
use of  the  eyes,  or  want  of  general  vigor,  in  young  adults. 
Anything  w4iich  lessens  the  importance  of  binocular  vision 
predisposes  to  divergent  squint,  e.  g.,  defective  sight  of  one 
eye  from  anisometropia  Latent  divergence  is  extremely 
apt  to  pass  gradually  into  manifest  permanent  divergent 
squint.  In  this  form  of  strabismus  the  eye  can  be  moved 
into  the  inner  canthus,  even  in  extreme  cases,  by  making 
the  patient  look  sideways,  though  not  by  efforts  at  con- 
vergence, and  it  is  thus  but  rarely  that  the  cases  simulate 
paralysis.  Tenotomy  of  the  external  rectus,  and  even 
**  advancement"  of  the  weakened  muscle,  are  often  needed. 
In  slight  cases  the  symptoms  are  sometimes  quite  cured  by 
wearing  prisms  with  their  bases  toward  the  nose;  but,  as 
far  as  I  know,  one  can  seldom  predict  success  with  any 
certainty  from  their  use.  One  of  the  most  troublesome 
features  in  muscular  asthenopia  is  its  great  variability  with 
the  patient's  state  of  health;  the  symptoms  sometimes  dis- 


368       STRABISMUS     AND     OCULAR     PARALYSIS. 

appear  entirely  in  a  bracing  climate,  returning  as  soon  as 
the  patient  comes  back  to  bis  less  invigorating  home  air. 

(3.)  Strabismus  from  disuse  is  also  nearly  always  diver- 
gent, depending,  as  it  does,  on  relaxation  of  the  internal 
rectus.  It  occurs  in  cases  where  convergence  is  no  longer 
of  service,  as  when  one  eye  is  blind  from  opacity  of  the 
cornea,  or  other  cause,  or  where  the  refraction  of  the  two 
eyes  is  very  different.  Tenotomy  of  the  external,  with  or 
without  advancement  of  the  internal,  rectus  may  be  per- 
formed. 

(4.)  Stretching  and  weakening  of  the  internal  rectus 
after  division  of  its  tendon  for  convergent  squint  may  give 
rise  to  divergence  simulating  that  caused  by  paralysis  of 
the  internal  rectus.  The  caruncle  in  these  cases,  however, 
is  generally  much  retracted,  and  this,  together  with  the 
history  of  a  former  operation,  will  prevent  any  mistake  in 
diagnosis.  Such  a  squint  can  always  be  lessened,  and  often 
quite  removed,  by  an  operation  for  readjustment  or  ad- 
vancement of  the  defective  muscle. 

(3.)  Paralytic  squint. — The  deviation  is  caused  by  the 
unopposed  action  of  the  sound  muscles.  When  the  palsied 
muscle  tries  to  act,  the  eye  fails,  in  proportion  to  the  weak- 
ness, to  move  in  the  required  direction.  In  many  cases 
there  is  only  slight  paresis,  and  the  resulting  deviation  is 
too  little  to  be  objectively  noticeable;  but  in  such  cases  the 
diplopia,  as  mentioned  already,  is  very  troublesome,  and  it 
is  for  this  symptom  that  the  patient  comes  under  care. 
Further,  in  these  slight  cases,  the  symptoms  often  vary  with 
the  effort  made  by  the  patient.  In  paralysis  of  the  third 
nerve,  the  several  branches  are  often  affected  in  different 
degrees,  and  the  strabismus  and  diplopia  are  then  complex. 
When  paralysis  of  any  ocular  muscle  is  of  long  standing, 
secondary  contraction  of  the  opponent  seems  sometimes  to 
occur,  and  complicates  the  symptoms.  Further  difficulty 
in  diagnosis  is  occasionally  caused    by  the  sound  yoke- 


STRABISMUS     AND     OCULAR    PARALYSIS.       869 

fellow'  of  the  paralyzed  muscle  acting  too  much,  in  obe- 
dience to  efforts  made  by  the  latter  ;  when  this  happens  the 
squint  will  sometimes,  even  when  both  eyes  are  uncovered, 
affect  the  sound  instead  of  the  paralyzed  eye,  i.  e.,  it  will 
alternate. 

The  commonest  forms  of  paralytic  squint  are  due  to 
affection,  separately,  of  the  external  rectus  (sixth  nerve), 
superior  oblique  (fourth  nerve),  or  of  one  or  all  of  the 
muscles  supplied  by  the  third  nerve  (internal,  superior, 
and  inferior  recti,  inferior  oblique,  levator  palpebrse).^ 

Paralysis  of  the  external  rectus  {sixth  nerve)  causes  a 
convergent  squint,  from  preponderance  of  the  internal 
rectus,  which,  except  in  the  slightest  cases,  is  usually  very 
noticeable.  Movement  straight  outward  is  impaired,  and 
if  the  paralysis  be  complete  the  eye  cannot  be  moved  out- 
ward beyond  the  middle  line  of  the  palpebral  fissure. 
There  is  homonymous  diplopia;  the  two  images,  when  in 
the  horizontal  plane,  are  upright  and  on  the  same  level ; 
the  distance  between  them  increases  as  the  object  is  moved 
toward  the  paralyzed  side,  but  it  diminishes,  or  the  images 
even  coalesce,  in  the  opposite  direction.  Thus  in  paralysis 
of  the  left  external  rectus.  Fig.  122,  uppermost  figure,  the 
images  separate  more  as  the  object  is  moved  to  the  patient's 
left,  but  approach  one  another,  and  finally  coalesce,  as  it 
is  moved  over  to  his  right.  In  slight  cases  the  diplopia 
ceases  when  the  patient  looks  at  an  object  a  few  inches  off, 
but  reappears  when  he  gazes  straight  forward  at  a  distant 
object.  In  the  upper  part  of  the  field  the  false  image  is 
sometimes  lower,  and  in  the  lower  part  of  the  field  higher, 

'  Yoked  or  conj  ugate  muscles  are  the  muscles  of  opposite  eyes  which 
act  together  in  producing  lateral  and  vertical  movements  \e.  g.,  the  in- 
ternal rectus  of  one  eye  acts  with  the  external  rectus  of  the  other  in 
movement  of  the  eyes  to  the  R.  or  L. 

2  In  77  cases  of  paralysis  of  a  single  oculo-motor  nerve  I  found  the 
third  nerve  affected  in  31  cases,  the  fourth  in  9,  and  the  sixth  in  37. 

16* 


370       STRABISMUS     AND     OCULAR     PARALYSIS. 

than  the  true  one.  I  have  many  times  noticed  that  the 
pupil  is  larger  in  the  affected  eye  than  in  the  other,  a  con- 
dition which  we  should  not  expect. 

In  paralysis  of  the  superior  oblique  {fourth  nerve)  there 
is  either  no  visible  squint,  or  only  a  slight  deviation  upward 
and  inward.  But  when  the  eyes  are  directed  below  the 
horizontal,  very  troublesome  diplopia  arises  from  the  defec- 
tive downward  and  outward  movement,  and  loss  of  rotation 
of  the  vertical  meridian  inward,  to  which  the  lesion  gives 
rise.  In  downward  movements,  especially  downward  and 
toward  the  paralyzed  side,  the  eye  remains  a  little  higher 
than  its  fellow  ;  in  trying  to  look  straight  down,  inferior 
rectus  and  superior  oblique,  the  unopposed  action  of  the 
inferior  rectus  carries  the  cornea  somewhat  inward,  con- 
vergent squint,  and  at  the  same  time  rotates  the  vertical 
axis  outward,  whilst  the  cornea  remains  on  a  rather  higher 
level  than  its  fellow  ;  in  following  an  object  from  the  hori- 
zontal middle  line  down-outward,  it  will  be  seen  that  the 
vertical  meridian  of  the  cornea  does  not,  as  it  should,  be- 
come inclined  inward. 

In  many  cases,  however,  the  slight  defects  of  movement 
caused  by  paralysis  of  the  superior  oblique  are  not  clearly 
marked,  and  the  diagnosis  has  to  be  based  on  the  characters 
of  the  diplopia.  In  all  positions  below  the  horizontal  line 
the  false  image  is  below  the  true  one,  and  displaced  toward 
the  paralyzed  side  (homonymous) ;  thus,  if  the  R.  muscle 
be  at  fault,  the  false  image  will  be  below  and  to  the 
patient's  K.,  Fig.  122,  arrow-head  figure ;  further,  it  is  not 
upright,  but  leans  toward  the  true  image.  The  difference 
in  height  between  the  images  is  greatest  in  movements 
toward  the  sound  side  ;  the  lateral  separation  is  greater  the 
further  the  object  is  moved  downward  ;  the  leaning  of  the 
false  image  is  greatest  in  movements  toward  the  paralyzed 
side.  When  the  patient  looks  on  the  floor,  i.  e.,  projects 
the  images  on  to  a  horizontal  surface,  the  false  image  seems 


STRABISMUS     AND     OCULAR     PARALYSIS.       371 

nearer  to  him  than  the  true  one.  The  images  are  always 
near  enough  together  to  cause  inconvenience,  and  as  the 
diplopia  is  confined  to,  or  is  worst  in,  the  lower  half  of  the 
field,  the  half  most  used  in  daily  life,  paralysis  of  the 
superior  oblique  is  very  annoying,  especially  in  going  up 
or  down  stairs,  in  looking  at  the  floor,  counting  money, 
eating,  etc. 

Fto.  1-22. 


Chart  showincr  position  of  double  iinau:es,  as  seen  by  the  patient  in 
paralysis  of  L.  external  rectus  and  R.  superior  oblique. 


Paralysis  of  the  third  nerve,  when  complete,  causes 
ptosis,  loss  of  inward,  upward,  and  downward  movements, 
loss  of  accommodation,  and  partial  mydriasis,  well-marked 
divergent  strabismus  from  unopposed  action  of  the  exter- 
nal rectus  and  crossed  diplopia.  The  downward  and  out- 
ward movement,  with  rotation  of  the  vertical  meridian 
inward  eflfected  by  the  superior  oblique,  remains.  The 
mydriasis  is  much  less  than  that  produced  by  atropine. 
In  man}^  cases  the  paralysis  is  incomplete,  affecting  some 
branches  (and  muscles)  more  than  others,  and  the  symp- 
toms are  then  less  typical.  Isolated  paralysis  of  a  single 
third-nerve  muscle  is  rare. 


372       STRABISMUS     AND     OCULAR     PARALYSIS. 

Peculiarities  of  paralytic  strabismus. — (1.)  Ifapatieot 
suffering,  e.  g.,  from  paresis  of  one  external  rectus,  look  at 
an  object  distant  about  two  feet,  and  the  sound  eye  be  then 
covered  by  holding  a  card  or  piece  of  ground-glass  before 
it,  the  paralyzed  eye  will  make  an  attempt,  more  or  less 
successful  according  to  the  degree  of  palsy,  to  look  at  the 
object.  The  movement  effected  will  call  for  a  greater 
effort  than  if  the  sixth  nerve  were  healthy,  and  as  the  eye 
muscles  always  work  in  pairs,  the  same  effort  will  be  trans- 
mitted to  the  internal  rectus  of  the  healthy  eye.  The 
latter  will,  in  consequence,  describe  a  larger  movement 
than  the  paralyzed  eye,  i.  e.,  the  secondary  squint  will  be 
greater  than  the  primary.  This  test  is  sometimes  of  use 
in  distinguishing  which  is  the  faulty  eye  in  cases  where  the 
squint  is  slight  and  the  patient  unable  to  distinguish  be- 
tween the  false  and  true  images.  (2  )  Giddiness  is  often 
present  when  the  patient  walks  with  the  sound  eye  closed. 
This  symptom  depends  on  an  erroneous  judgment  of  the 
position  of  surrounding  objects,  which  is  caused  by  the 
weakened  muscle  not  being  able  to  achieve  a  movement  of 
the  eye  corresponding  in  magnitude  to  the  effort  made  It 
is  absent  when  both  eyes  are  open,  and  when  the  paralyzed 
eye  is  covered.  It  often  helps  us  more  than  does  the 
former  symptom  in  determining  which  is  the  faulty  eye; 
but  it  varies  much  in  severity  in  different  cases,  and  may  be 
quite  absent.  Patients  with  ocular  palsy  often  keep  one  eye 
closed,  nearly  always  the  paralyzed  one,  to  avoid  diplopia. 

Paralysis  of  the  ocular  muscles  is  seldom  .symmetrical ; 
in  the  rare  cases  where  it  is  so,  the  disease  is  usually  intra- 
cranial In  uncomplicated  symmetrical  "ophthalmoplegia 
externa,"  paralysis  of  all  the  external  muscles,  the  iris  and 
ciliary  muscles  escaping,  the  disease  is  usually  nuclear, 
whilst  in  cases  of  symmetrical  disease  of  oculo-motor  nerve 
trunks,  both  external  and  internal  muscles  are  paralyzed  ; 
but    even    in    nuclear    ophthalmoplegia   the    disease   may 


AFFECTIONS     OF     MUSCLES     OF     EYEBALL.       373 

spread  forward  and  attack  the  centres  for  the  iris  and 
ciliary  muscle,  and  the  diflerential  diagnosis  may  then  be 
exceedingly  difficult  to  make.  In  the  later  stages  of  nuclear 
ophthalmoplegia,  other  cranial  nerves,  especially  the  optic 
and  fifth,  may  be  involved,  and  symptoms  of  spinal  or 
bulbar  disease  be  present. 

It  is  believed,  as  the  result  chiefly  of  experiments  by  Hensen 
and  YoU-kers,  that  there  are  separate  centres  for  different  parts 
of  the  third  (and  fourth)  nerve  in  the  floor  of  the  aqueduct  of 
Sylvius  ;  most  anteriorly  is  the  centre  for  accommodation,  next 
that  for  the  sphincter  of  the  pupil,  next  for  the  internal  recti 
(convergence),  and  further  back  those  for  the  other  ocular 
muscles.  It  has  also  been  made  out  that  there  is  a  direct  con- 
nection between  the  nucleus  of  tlie  sixth  nerve  on  one  side,  and 
part  of  the  fibres  of  the  third  and  fourth  on  the  opposite  side,  an 
arrangement  which  may  explain  the  association  of  the  external 
rectus  of  one  eye  with  the  internal  of  the  other  in  looking  side- 
ways. Mauther  suggests  that  the  limitation  of  nuclear  ocular 
palsies  to  the  external  muscles  in  some  cases,  and  to  the  in- 
ternal muscles  in  others,  may  be  explained  by  vascular  supply  ; 
the  centres  for  accommodation  and  pupil  being  fed  by  the 
posterior  communicating  artery,  the  centres  for  the  external 
muscles  by  the  posterior  cerebral. 

Affections  of  the  Internal  Muscles  of  the 
Eyeball. 

Physiological  outline. — The  nerves  of  the  iris  are:  a,  The 
third  for  contraction  of  the  pupil ;  6,  the  cervical  sympathetic 
for  its  dilatation  ;  and  c,  the  fifth  supplying  sensory  fibres.  The 
sympathetic  fibres  [h)  come  from  the  cord  probably  through 
the  anterior  root  of  the  second  dorsal  nerve  and  reach  the  eye 
— (1)  through  the  Gasserian  ganglion  from  the  carotid  plexus  ; 
(2)  through  the  lenticular  ganglion  from  the  cavernous  plexus  ; 
(8)  it  is  stated  that  sympathetic  (dilator)  fibres  accompany  the 
fifth  nerve  directly  from  its  origin.  The  ciliary  muscle  has  not 
hitherto  been  thought  to  contain  any  nerve-fibres  correspond- 


374       STRABISMUS     AND     OCULAR     PARALYSIS. 

ing  to  the  dilator  nerves  of  tlie  iris,  but  it  is  now  tliouglit,  by 
Jessop,  that  such  fibres,  capable  of  causing  complete  relaxa- 
tion, are  present  in  the  long  ciliary  nerves.  The  filaments  of 
the  fifth  (c),  form— (1)  the  long  root  of  the  lenticular  ganglion 
(whicligivesoff  the  short  ciliary  nerves)  ;  (2)  the  long  ciliaries, 
two  or  three  in  number,  independent  of  the  ganglion.  The 
human  iris  contains  a  circular  (sphincter)  unstriped  muscle 
close  to  the  pupil ;  but  there  seems  to  be  no  dilator  muscle, 
the  thin  layer  of  radiating  fibrous  structure  with  staff'-shaped 
nuclei,  which  lies  immediately  beneath  {i.  e.,  in  front  of)  the 
uveal  layer,  being  probabl}'  only  elastic' 

If  the  third  nerve  be  divided  or  paralyzed,  the  pupil  dilates 
moderately  (never  extremely)  and  becomes  motionless  to  light 
and  accommodation,  and  accommodation  is  lost.  Of  contrac- 
tion of  pupil  and  spasm  of  accommodation  from  irritation  of 
the  nerve,  we  have  little  clinical  knowledge;  but  experimental 
stimulation  of  the  nerve  produces  those  effects.  Section,  or 
paralysis  of  the  cervical  sympathetic  causes  some  contraction 
of  pupil  and  destroys  its  power  of  dilating  when  shaded  ;  stimu- 
lation of  it,  or  of  the  anterior  root  of  the  second  dorsal  (in 
monkeys,  Terrier),  causes  well-marked  dilatation,  wdiich,  how- 
ever, is  less  than  that  due  to  atropine  ;  irritation  of  the  skin, 
stimulating  the  dilator  nerve,  causes  slight,  momentary  dila- 
tation. 

All  the  drugs  which  act  upon  the  iris  act  upon  the  ciliary 
muscle  too,  but  the  iris  is  afiected  sooner,  for  a  longer  time, 
and  by  weaker  solutions,  than  the  ciliary  muscle. 

Atropine^  dilates  the  pupil  and  paralyzes  the  accommodation; 
the  effect  on  the  pupil  in  old  people  is  often,  and  in  children 
sometimes,  lessened;  the  mydriasis  of  atropine  is  greater  than 
that  due  to  paralysis  of  a  third  nerve,  but  is  somewhat  increased 
if  the  third  nerve  be  cut.  It  acts  in  old-standing  paralysis  of 
iris  (third  nerve)  and  of  cervical  sympathetic,  but  in  both  con- 
ditions the  mydriasis  is  apt  to  be  rather  less  than  full ;  the 

1  The  different  views  that  have  been  held  by  various  anatomists  as 
to  the  nature  of  this  layer  (Henle's  layer)  show  that  the  question  is 
exceedingly  difficult  to  decide  on  microscopical  evidence  alone. 

'^  And  all  the  mydriatics  except  cocaine. 


AFFECTIONS     OF     MUSCLES     OF     EYEBALL.       375 

mydriasis  is  said  to  be  rather  increased  b}-  stimulating  the  long 
ciliary  nerves,  and  diminished  by  cutting  the  fifth.'  Atropine 
dilates  the  pupil  of  a  freshly  excised  (rabbit's)  eye,  and  of  the 
eye  of  an  animal  bled  to  death,  and  it  acts  a  little  if  put  on  to 
the  human  eye  very  soon  after  death.  From  the  above  it  is 
inferred  that  atropine  acts  directly  upon  the  muscular  fibres, 
paralyzing  them,  and  not  upon  the  nerve  fibres.  Atropine  does 
not  act  upon  the  iris  of  birds  (containing  striped  muscle). 

Eserine^  contracts  the  pupil  and  causes  spasm  of  accommo- 
dation :  it  has  the  same  action  in  long-standing  paralysis  of  iris 
(third  nerve),  and  after  section  of  the  third  nerve  and  of  the 
sympathetic  ;  it  has  very  little  effect  if  atropine  have  been  used, 
but  it  immediately  overcomes  the  mydriasis  of  cocaine.  Eserine 
therefore  probably  acts  directly  on  the  muscular  fibres,  stimu- 
lating them. 

Cocaine  dilates  the  pupil,  but  does  not  prevent  its  action  to 
light  and  accommodation, and  has  but  little  action  on  the  ciliar}'- 
muscle  ;  hence  it  does  not  act  by  paralyzing  either  the  third 
nerve  fibres  or  the  muscular  fibres.  It  causes  further  dilatation 
of  a  pupil  dilated  by  atropine  or  by  section  of  third  nerve  ; 
whilst  it  does  not  dilate  the  pupil  if  the  cervical  sympathetic 
have  been  cut  or  paralyzed  for  some  little  time.  It  also  causes 
retraction  of  the  eyelids  and  contraction  of  the  superficial  blood- 
vessels of  the  eye.  Hence,  cocaine  probably  acts  by  stimulating 
the  sympathetic  nerve  fibres.  (Consult  Michael  Foster's  Physi- 
ology; Ferrier,  Functions  of  Brain  {2d  ed.) ,  and  P roc.  of  Boy. 
Soc,  1883;  Gowers,  Diseases  of  Nervous  System,  vol.  i.;  Jes- 
sop,  Proc.  of  Boy.  «Soc.,  1885-6  ;  Marshall,  Lancet,  1885,  ii. 
280  ;  Author's  own  cases.) 

The  following  forms  of  paralysis,  or  altered  innervation, 
of  iris  and  ciliary  muscle  agree  tolerably  with  the  above 
physiological  facts : 

A.  Pupil  alone. — (1  )  Paralysis  of  dilatation  :  Pupil  in 
good  light,  equal  to  or  smaller  than  the  other ;  but  when 

1  The  relation  of  the  fifth  nerve  to  the  iris  is  evidently  not  yet  fully 
understood. 

2  And  pilocarpine. 


376       STRABISMUa     AND     OCULAR     PARALYSIS. 

shaded,  dilates  little,  if  at  all,  so  that  in  dull  light  it  is 
much  the  smaller,  paralytic  miof<is ;  accommodation  not 
affected.  Tliis  uncommon  condition  is,  when  well  marked, 
generally  one-sided,  and  due  to  paralysis  of  cervical  sym- 
pathetic by  pressure,  e.  g.,  by  aneurism  or  tumor  at  the  root 
of  the  neck,  or  injury  to  the  brachial  plexus;  it  should 
therefore  always  lead  to  careful  examination,  A  degree  of 
miosis  and  non-dilatability  of  pupils  is  common  in  old  age. 
(2.)  The  opposite  sisite, spasmodic  viyd7nasis,is  very  rare  as 
a  permanent  symptom,  though  temporary,  varying  dila- 
tation of  one  pupil  is  sometimes  seen  in  young  or  neurotic 
persons.  Persistent  spasmodic  mydriasis  is  said  to  occur  in 
the  early  irritative  stage  of  lesions  which  afterward  pro- 
duce paralytic  miosis  ;^  in  this  state  we  should  expect  the 
pupil,  though  dilated,  to  act  both  to  light  and  to  accom- 
modation, as  after  cocaine,  (3.)  Of  paralytic  mydriasis' 
paralysis  of  third-nerve  fibres  of  the  sphincter  muscle 
without  paralysis  of  accommodation,  we  know  but  little, 
except  in  a  slight  degree  as  a  residue  after  recovery  from 
the  double  condition,  paralysis  of  the  sphincter  iridis  and 
ciliary  muscle,  the  pupil  often  not  recovering  so  well,  or  so 
soon,  as  the  accommodation  ;  compare  the  action  of  the  drugs 
above  given.  (4.)  Paralysis  of  iris,  iridoplegia,  w^ithout 
defect  of  accommodation,  usually  affects  only  the  action  to 
light,  reflex  iridoplegia,  the  associated  action  remaining. 
It  occurs  as  a  very  early  symptom  in  locomotor  ataxy,  and 
sometimes  without  any  other  symptoms  of  that  disease,  and 
should  always  lead  to  full  investigation.  It  is  probably 
due  to  degeneration  in  that  part  of  the  nucleus  of  the  third 
which  presides  over  the  reflex  action  of  the  pupil. 

1  Gowers,  Dis.  of  Nervous  Sys.,  i.  152.  I  can  hear  very  little  of  this 
symptom  from  physicians,  and  I  have  only  ouce  seen  anything  of  the 
kind. 

*  See  several  cases  reported  by  the  author  in  Ophth.  Hosp.  Reports, 
vol.xi.,iii.,  pp.  260-264. 


AFFECTIONS     OF     MUSCLES     OF     EYEBALL.       37  7 

B.  Paralysis  of  accommodation  alone  {cyclopJegia)  is 
often  seen  after  diphtheria.  It  is  often  incomplete,  and 
the  pupils  are  usually  unaffected ;  but  if  the  cycloplegia 
be  complete  there  is  sometimes  mydriasis.  In  ataxy  there 
is  occasionally  cycloplegia  with  a  pupil  active  to  light. 
Accommodation  is  sometimes  quite  lost  without  any  altera- 
tion of  pupil  in  what  is  spoken  of  as  premature  presbyopia, 
but  this  is  not  called  cycloplegia,  not  being  supposed  to  be 
paralytic. 

c.  Ciliary  muscle  and  iris  affected. — (1)  Ci/cloplegia 
with  mydriasis ;  loss  of  accommodation  and  pupil  dilated  to 
about  5  mm.  and  motionless;  the  ordinary  condition  in 
complete  paralysis  of  third  nerve.  It  is  now  and  then  seen 
without  failure  of  any  other  part  of  the  third  nerve,  and 
the  pupil  may  then  be  quite  widely  dilated.  When  an  old 
person  gets  paralysis  of  the  third,  the  pupil  is  often  very 
little  dilated.  (2)  Total  iridoplegia,  with  cycloplegia, 
ophthalmoplegia  interna;  accommodation  lost;  pupil  mo- 
tionless to  reflex  and  associated  stimuli,  and  of  medium 
size ;  this  is  sometimes  a  later  stage  of  (a.  4),  but  it  may 
be  primary  ;  the  paralysis,  both  of  iris  and  ciliary  muscle, 
is  often  incomplete.  In  paralysis  of  sixth  nerve,  the  pupil 
of  the  paralyzed  eye  is  often  rather  larger  than  that  of  the 
other. 

Causes  of  ocular  paralysis. — It  is  convenient  to  separate 
the  external  and  mixed  forms  from  those  in  which  only  the 
internal  muscles  are  involved,  since  the  local  lesions  are, 
as  a  rule,  different  in  the  two  groups. 

Paralysis  of  the  third,  fourth,  or  sixth  nerve,  may  be  the 
result  of  tumors  or  other  growths  in  the  orbit,  but  in  such 
cases,  as  a  rule,  the  paralysis  forms  only  one  amongst  other 
well-marked  local  symptoms.  In  the  vast  majority  of  un- 
complicated ocular  palsies  we  are  quite  unable  to  decide, 
either  from  the  state  of  the  eye,  or  the  orbital  parts,  whether 
the  lesion  be  in  the  orbit  or  within  the  cranium.     Menin- 


3T8       STRABISMUS     ASD     UCULAR     PARALYSIS. 

giti.-^,  morbid  growths,  and  syphilitic  periostitis  at  the  base 
of  the  skiill,  or  involving  the  sphenoidal  fissure,  often  cause 
ocular  pals}',  seldom  confined  to  one  nerve,  and  aneurism 
of  the  internal  carotid  in  the  cavernous  sinus  occasionally 
does  so.  Syphilitic  gumma  of  the  nerve-trunk  is  probably 
the  commonest  cause  of  single  paralysis;  the  intracranial 
portion  of  the  nerves  is  known  to  be  often  the  seat  of  such 
growths,  but  small  neural  guramata  probably  occur  also 
on  the  orbital  part  of  the  nerves.  Injuries  to  the  head 
often  cause  ocular  paralysis;  the  paralysis  is  usually  noticed 
very  soon  after  the  accident,  and  is  probably  always  a  sign 
of  fracture  of  the  base  involving  the  middle  fossa,  or  of 
some  part  of  the  walls  of  the  orbit.  Direct  damage  to,  or 
thickening  subsequent  to  fracture  near  the  pulley,  seems  to 
account  for  some  cases  of  traumatic  paralysis  of  the  superior 
oblique.  Pain  in  the  temple  or  front  of  the  head  is  very 
common  in  ocular  palsies  due  to  periostitis  and  gummata. 
In  certain  cases  neither  the  symptoms  nor  history  enable 
us  to  locate  the  seat  or  prove  the  cause  of  the  paralysis;  the 
term  "  rheumatic"  is  often  applied  to  such  cases,  on  the 
assumption  that  the  palsy  is  peripheral  and  caused  by  cold, 
that  it  is,  in  fact,  to  be  compared  to  peripheral  paralysis  of 
the  facial  nerve ;  no  doubt  some  of  these  are  in  reality 
syphilitic.  Paralysis,  usually  of  short  duration  and  affect- 
ing only  one  nerve,  is  not  uncommon  at  any  early  stage  of 
locomotor  ataxy.  Ophthalmoplegia  externa  generally  sets 
in  slowly,  is  bilaterally  symmetrical  and  permanent ;  it 
usually  indicates  sclerotic  disease  of  the  nerve  centres, 
often  caused  by  syphilis  ;  but  it  is  sometimes  caused  by 
tumor  centrally  placed,  or  by  symmetrical  gummata  on 
nerve-trunks.  Occasionally  ocular  palsies  are  "  func- 
tional," or  occur  in  company  with  symptoms  apparently 
of  hysterical  nature,  and  pass  ofi".  Paralysis  of  oculo- 
motor muscles  is  in  rare  cases  congenital,  and  occurring 
in  several  members  of  the  same  fa  rail  v.     These  cases  are 


AFFECTIONS     OF     MUSCLES     OF     EYEBALL.      379 

perhaps  of  the  same  nature  as  those  of  congenital  ptosis, 
absence  or  imperfect  development  of  muscles.  Occasion- 
ally paralysis  of  oculo-motor  nerves  from  birth  has  been 
attributed  to  instrumental  labor. 

In  respect  to  the  causation  of  the  purely  internal  paral- 
yses we  have  but  little  positive  knowledge  Mydriasis  with 
cycloplegia  and  no  other  paralysis,  would  be  accounted  for 
by  disease  of  the  short  (third-nerve)  root  of  the  lenticular 
ganglion.  Iridoplegia  and  ophthalmoplegia  interna  are 
probably  the  result  of  chronic,  very  strictly  localized, 
disease  of  the  centres  for  the  pupil  and  accommodation 
(Gowers),  which  have  been  shown  to  form  separate  parts  of 
the  nucleus  of  the  third  nerve.  Complete  ophthalmoplegia 
interna  would  also  be  expected  if  the  lenticular  ganglion 
(Hutchinson),  or  the  intra-ocular  ganglionic  cells  of  the 
choroid  (Hulke),  were  disorganized ;  but  such  changes 
have  not  yet  been  proved  post  mortem.  Paralysis  from 
blows  on  the  eye  is  referred  to  at  p.  180.  (See  also  Diph- 
theria, Chap.  XXIII.) 

Treatment  of  Ocular  Paralyses. — In  estimating 
the  results  of  treatment  it  is  well  to  remember  that  some 
cases  recover  spontaneously,  that  in  many  the  defect  is  a 
paresis  rather  than  paralysis,  and  that  in  the  latter  cases 
the  symptoms  often  vary  in  severity  from  day  to  day,  or 
even  whilst  under  observation  at  a  single  visit,  according 
to  the  attention  given  and  effort  made  by  the  patient.  The 
questions  of  syphilis  and  of  injury  to  the  head  must  always 
be  carefully  inciuired  into,  especially  when  only  one  nerve 
is  paralyzed.  When  several  nerves  are  involved,  tumor, 
aneurism,  or  syphilis,  either  gummatous  inflammation  at 
the  base,  or  sclerotic  nuclear  disease,  is  to  be  suspected. 
Iodide  of  potassium  and  mercury  are  the  only  internal 
remedies  likely  to  be  beneficial,  and  unless  syphilis  be  quite 
out  of  the  question  they  should  have  a  full  trial ;  many 
cases   recover   quickly  under   moderate   doses  of  iodide. 


380       STRABISMUS     AND     OCULAR     PARALYSIS. 

Faradization  of  the  paralyzed  muscles  is  sometimes  used. 
Operation  for  paralytic  squint  of  old  standing  may  some- 
times be  undertaken.* 

Nystagmus  (involuntary  oscillating-  movement  of  the 
eyes)  is  generally  associated  with  serious  defect  of  sight 
dating'from  very  early  life,  such  as  opacity  of  the  cornea 
after  ophthalmia  neonatorum,  congenital  cataract,  choroido- 
retinitis,  or  disease  of  the  optic  nerve.  It  is,  however,  also 
seen  in  cases  of  infantile  amblyopia  without  apparent  cause, 
and  constantly  in  albinoes.  Nystagmus  is  often  developed 
during  adult  life  in  coal-miners;  it  has  been  attributed  to 
the  insuflBciency  of  light  furnished  by  the  safety  lamps, 
and  with  more  probability  to  the  necessity  which  the  miner 
is  under  of  constantly  looking  in  an  unnatural  direction, 
upward  or  sideways,  for  example.  It  is  often  present  only 
when  the  collier  takes  up  his  mining  posture.  Nystagmus 
also  occurs  as  a  symptom  in  some  cases  of  disseminated 
sclerosis,  and  in  other  forms  of  central  nervous  disease. 

Usually  both  eyes  oscillate,  but  when  only  one  eye  is  de- 
fective, it  alone  may  oscillate.  The  movements  in  nystag- 
mus, whatever  the  cause  of  the  condition,  vary  much  in 
rapidity,  amplitude  and  direction  in  different  cases,  and 
even  in  the  same  case  at  different  times  ;  they  are  generally 
worse  when  the  patient  is  nervous,  and  often  there  is  a  par- 
ticular position  of  the  eyes  in  which  the  oscillation  is  least. 
Nystagmus  often  becomes  much  less  marked  as  life  advances. 
Treatment  is  useless. 

^  Rules  for  operations  for  paralytic  squint  have  been  laid  down  by 
Alfred  Graefe,  Arch.  f.  Oph.,  xxxiii.  3,  179. 


CHAPTER    XXII. 

OPERATIONS. 

A.  Operations  on  the  Eyelids. 

1.  Epilation  of  eyelashes Position:    Patient  seated; 

surgeon  standing  behind.  The  forceps  to  be  broadened, 
with  smooth,  or  very  finely  roughened,  blades  which  meet 
accurately  in  their  whole  width.  Stretch  the  lid  tightly 
by  a  finger  placed  over  each  end.  Pull  out  the  lashes  at 
first  quickly  in  bundles,  and  finish  by  carefully  picking  out 
the  separate  ones  that  are  left. 

2.  Eversion  of  upper  lid. — Position  as  for  1,  or  the  sur- 
geon may  stand  in  front.  The  patient  looks  down,  a  probe 
is  laid  along  the  lid  above  the  upper  edge  of  the  "carti= 
lage  ;"  the  lashes,  or  the  edge  of  the  lid,  are  then  seized  by 
a  finger  and  thumb  of  the  other  hand,  and  turned  up  over 
the  probe,  which  is  simultaneously  pushed  down.  After  a 
little  practice  the  probe  can  be  dispensed  with,  and  the  lid 
everted  by  the  forefinger  and  thumb  of  one  hand  alone, 
one  serving  to  fix  and  depress  the  lid,  the  other  to  turn  it 
upward. 

Fig.  123. 


Meibomian  scoop. 

3.  Removal  of  Meibomian  cyst. — Position  as  for  1.  In- 
struments :  A  small  scalpel  or  Beer's  knife,  Fig.  159,  and  a 
curette,  or  small  scoop  ;  Figs.  123  and  156.     (1)  Evert' the 


OPERATIONS. 

lid  ;  (2)  make  a  free  crucial  incision  into  the  tumor  from 
the  conjunctival  surface  ;  (3)  remove  the  growth,  either 
by  squeezing  the  lid  between  finger-  and  thumb-nail,  or  by 
means  of  the  scoop.  The  cavity  fills  with  blood,  and  may 
thus  for  a  few  days  be  larger  than  before.  These  tumors 
have  no  distinct  cyst-wall. 

4.  Inspection  of  cornea  in  purulent  ophthalmia,  etc. 
Position  :  If  the  patient  be  a  baby  or  child,  the  back  of  its 
head  is  to  be  held  between  the  surgeon's  knees,  its  body 
and  legs  being  on  the  nurse's  lap  ;  if  an  adult,  the  same  as 
for  1.  If  the  lids  cannot  be  easily  separated  by  a  finger 
of  each  hand,  enough  to  allow  a  view  of  the  cornea,  re- 
tractors should  be  u.sed — a  convenient  pattern  is  shown  iu 
Fig.  124 — by  which  one  lid,  or  both,  can  be  raised  and  held 

Fig.  124. 


Desmarres'  lid  elevator. 

away  from  the  globe.  If  this  instrument  be  gently  used 
we  avoid  all  risk  of  causing  perforation  of  the  cornea 
should  a  deep  ulcer  be  present ;  an  accident  which  may 
happen  in  cases  attended  by  much  swelling  or  spasm  of  the 
lids  if  the  fingers  be  used. 

5.  Entropion. — Spasmodic  entropion  of  the  lower  lid, 
with  relaxed  skin,  in  old  people.  Position  as  for  1.  In- 
struments:  T-forceps,  Fig.  125,  scissors,  Fig.  140,  toothed 
forceps.  With  the  T-forceps  pinch  up  a  fold  of  skin  as  close 
as  possible  to  the  edge  of  the  lid,  and  of  width  proportion- 
ate to  the  degree  of  inversion,  and  cut  it  off  close  to  the 
forceps  ;  now  pinch  up  and  cut  out  a  portion  of  the  exposed 
orbicularis  muscle  ;  ..sutures  need  not  be  used.     Another 


OPERATIONS     ON     THE     EYELIDS 


383 


good  plan  is  to  enter  a  threaded  needle  close  to  the  edge  of 
the  lid,  bring  it  out  half  an  inch  vertically  belov\^,  tie  the 
intervening  skin  and  muscle  tightly  and  allow  the  thread 
to  cut  its  way  out ;   two  or  three  such   stitches  will  be 


Fig.  125. 


Entropion  forceps. 

wanted  at  equal  distances  apart ;  the  resulting  scars  being 
vertical  are  rather  conspicuous. 

6.  Organic  entropion  and  trichiasis. — When  the  whole 
row  of  lashes  is  turned  inward,  and  the  inner  surface  of 
the  lid  much  shortened  by  scarring,  the  radical  extirpation 
of  all  the  lashes  is  the  quickest  and  most  certain  means  of 
giving  permanent  relief,  but  it  leaves  an  unsightly  baldness 
and  exposes  the  cornea  to  unnatural  risk  from  dust,  etc. 
Position :  Recumbent;  the  surgeon  stands  behind  the  pa- 
tient. Anaesthesia  seldom  necessary.  Instruments:  A  horn 
or  bone  lid-spatula,  Fig.  127,  s,  or  a  lid  clamp.  Fig.  126,  a 
Beer's  knife.  Fig.  159,  and  forceps.  Make  an  incision  from 
end  to  end,  beginning  just  outside  the  punctum,  between 
the  hair-follicles  and  Meibomian  ducts,  as  if  to  split  the  lid 
into  two  layers.  Make  a  second  incision  through  the  skin 
and  tissues,  about  a  twelfth  of  an  inch  above  the  border 


384 


OPERATIONS. 


of  the  lid,  parallel  with,  but  in  a  plane  at  right  angles  to, 
the  first.  The  strip  of  skin  and  tissues  included  between 
these  two  cuts  will  now  be  almost  free,  except  at  its  ends, 
which  are  to  be  united  by  a  cross-cut,  and  the  strip  dis- 
sected off;  it  should  include  the  hair-follicles  in  their  whole 


Snellen's  lid  clamp  (for  the  R.  upper  lid). 


depth.  Examiae  the  white  edge  of  the  "cartilage,"  now 
exposed,  for  any  hair-follicles  accidentally  left  behind; 
they  will  appear  as  black  dots,  and  are  to  be  carefully 
removed. 

In  the  same  or  slighter  cases,  the  inversion  of  the  border 
of  the  lid  may  be  much  lessened  by  complete  division  of 
the  "cartilage"  from  the  conjunctival  surface  along  a  line 
parallel  with,  and  3  mm.  from  the  free  border  (Burow's 
operation),  Fig.  128,  Bu.  The  wound  gapes  and  the  in- 
verted border  of  the  lid  falls  forward  and  is  kept  in  its 
natural  place  by  the  cornea.  The  only  instruments  needed 
are  a  scalpel  and  scissors.  Position  as  for  1,  or  recumbent. 
The  lid  is  kept  well  everted  while  the  incision  is  being 
made.  A  puncture  is  made  with  the  knife  parallel  to  the 
edge  of  the  lid,  close  to  the  inner  or  outer  end,  one  blade 


OPERATIONS    ON     THE     EYELIDS.  385 

of  the  scissors  passed  through  this  puncture  and  made  to 
run  along  the  outer  surface  of  the  "cartilage"  between 
it  and  the  orbicularis  muscle,  and  then  the  ''cartilage" 
divided  by  closing  the  blades  parallel  to  the  border.  The 
wound  should  be  at  right  angles  to  the  surface.    A  bluish 

Fig.  127. 


Arlt's  operation  for  trichiasis.     (After  Schweigger.) 

line  should  be  seen  through  the  skin  on  replacing  the  lid. 
This  operation  gives  complete  relief  for  the  time,  but  may 
need  repetition  in  a  few  months. 

Various  operations  are  performed  for  transplantation  of 
the  displaced  lashes  forward  and  upward,  so  as  to  restore 
their  natural  direction.  ArlVs  operation:  The  free  border 
of  the  lid  is  split  from  end  to  end,  leaving  the  punctum  as 
for  extirpation  of  the  lashes,  but  more  deeply.  Fig.  127,  a. 
A  second  incision  (6),  extending  beyond  the  ends  of  the 
first,  is  now  made  through  the  skin  parallel  to,  and  about 
two  lines  from,  the  border  of  the  lid,  and  down  to,  but  not 
through  the  "cartilage;"  thirdly,  a  curved  incision  (c)  is 
made,  joining  h  at  each  end  and  including  a  semilunar  flap 
of  skin,  of  greater  or  le?=  width  according  to  the  effect 

17 


386 


OPERATIONS. 


desired  ;  fourthly,  this  flap  is  dissected  off  without  injury 
to  the  orbicularis,  and  the  wound,  bounded  by  the  lines  h 
and  c,  closed  by  sutures.  The  anterior  layer  of  the  lid 
border,  which  contains  the  lashes,  is  thus  tilted  forward 
and  drawn  upward. 


Fig.  128. 


Fig.  129. 


Snellen's  operation  for  trichiasis. 
(After  Wecker. )  s.  Edge  of  retracted 
skin  and  muscle. 


Diagrammatic  section  of 
upper  lid ;  showing  Snel- 
len's operation,  and  line  of 
section  in  Burow's  opera- 
tion (Bu).  (Altered  from 
Wecker. ) 


A  third  operation  (Streatfeild's) 
consists  in  the  sinijile  removal  of 
a  wedge-shaped  strip  of  the  "car- 
tilage," wnth  its  superjacent  skin 
and  muscle,  from  the  whole  length 
of  the  lid,  at  a  distance  of  a  line 
or  two  from  its  border,  h,  Fig.  127.  No  sutures  are  used. 
Snellen  operates  as  follow^s:  The  incision,  h,  Fig.  127,  is 
carried  down  to  the  tarsus,  the  muscle  and  skin  separated 
from  it  and  pushed  upv/ard,  and  a  wedge,  shown  by  the 
groove  in  Fig.  128,  cut  from  the  exposed  tarsus,  as  in 
Streatfeild's  operation.  The  border  of  the  lid  is  now 
everted,  and  kept  in  its  new  position  by  passing  two  or 
three  threads,  as  shown  in  Figs.  128  and  129,  and  tying 
them  over  beads,     The  skin  wound  need  not  be  sutured. 


OPERATIONS     ON     THE     EYELIDS.  387 

All  these  operations  (except  1)  are  apt  to  need  repetition 
sooner  or  later. 

The  above  operations  are  most  suitable  when  the  whole 
length  of  the  upper  lid  is  affected  ;  in  most  hands  Arlt's 
proceeding  probably  gives  better  average  results  than  any 
other.  In  cases  of  partial  trichiasis,  u'here  only  a  part  of 
the  border  is  affected,  these  operations  sometimes  only 
transfer  the  seat  of  the  affection,  by  causing  displacement 
of  the  adjacent  healthy  lashes.  In  such  cases,  transplan- 
tation of  a  strip  of  mucous  membrane  from  the  patient's 
lip,  into  the  gap  made  by  splitting  the  diseased  part  of  the 
lid,  Fig.  130,  is  the  best  operation.  This  may  be  done  as 
follows  (van  Millingen)  :  (1)  Split  the  affected  part  of  the 

Fig.  130. 


"^^rfy^i^ 


Van  Millingen's  operation. — 1st  stage  ;  the  portion  of  lid  containing 
misdirected  lashes  split  parallel  to  its  surfaces,  leaving  the  lashes  in 
the  anterior  layer.  The  incision  at  each  end  is  carried  a  short  distance 
into  the  skin  at  a  right  angle  with  the  split. 

lid  as  in  Arlt's  operation,  but  turn  the  cut  forward,  into 
the  skin  a  little  at  each  end,  as  in  Fig.  130.  (2)  Separate 
a  strip  of  mucous  membrane  from  the  lower  lip,  parallel 
to  its  length,  leaving  its  ends  attached ;  the  strip  should 
be  longer  and  wider  than  the  gap  it  is  to  fill.  (3)  Take 
two  needles,  each  with  a  long  thread  attached,  and  pass 
one  through  each  end  of  the  lid  incision  from  the  skin  sur- 
face into  the  angle  of  the  wound,  draw  the  needles  through, 


388  OPERATIONS. 

carry  them  down  to  the  lip,  and  pass  each  one  through  the 
corresponding  end  of  the  bridge  of  mucous  membrane  from 
the  deep  to  the  free  surface.  (4)  Cut  the  attached  ends  of 
the  bridge,  turn  the  strip  over  on  the  thumb-nail,  and  clean 
its  under  surface  with  scissors,  taking  care  not  to  cut  the 
thread  at  each  end.  (5)  Draw  the  strip  up  into  its  new 
position  by  pulling  on  the  upper  ends  of  the  threads,  and 
tie  the  threads.  A  very  fine  stitch  may  be  inserted  at  the 
centre  of  the  flap,  if  thought  necessary,  but  this  can  be 
dispensed  with.  The  split  in  the  lid  should  be  cleaned 
from  clot  before  the  strip  is  brought  into  position.  The 
strip  usually  lives  and  adheres  w^ell  under  an  antiseptic 
dressing  ;  the  stitches  may  be  left  to  come  out. 
■  T.  Ectropion Ectropion  from  thickening  of  the  con- 
junctiva, aided  by  relaxation  of  the  tissues  of  the  lower 
lid,  seen  chiefly  in  old  people,  may  be  treated  by  the  re- 
moval of  a  Y-shaped  piece  of  the  whole  thickness  of  the  lid, 
the  edges  being  brought  together  with  a  harelip-pin ;  or 
the  everted  mucous  membrane  may  be  drawn  back  into  the 
sulcus  between  lid  and  globe  by  a  suture,  entered  into  the 
conjunctiva  at  two  points  ^  inch  apart,  passed  deeply, 
brought  out  on  the  cheek,  and  tied  over  a  bit  of  India- 
rubber  tube  ;  the  thread  is  tightened  from  day  to  day  until 
it  has  nearly  cut  through  (Snellen).  An  operation  of 
which  the  principle  is  nearly  the  same,  but  the  execution 
more  complicated,  is  described  by  Argyll  Kobertson.^ 
Slighter  cases  may  be  satisfactorily  treated  by  the  excision, 
or  destruction  by  burning  deeply  with  a  fine  galvanic  cau- 
tery, of  a  strip  of  the  palpebral  conjunctiva  parallel  to  the 
border  of  the  lid;  the  contraction  of  the  scar  draws  the 
margin  of  the  lid  into  place. 

For  ectropion  from    cicatricial  changes  in   the  skin   a 
plastic  operation  is  generally  needed.     At  the  same  time 

1  A.  Robertson,  Kdin.X311n.  and  Path.  Journ.,  Dec.  1883. 


OPERATIONS     ON     THE     EYELIDS.  389 

the  eyelids  should  be  united  by  fine  sutures,  after  paring  a 
narrow  strip  from  the  border  of  each  lid  just  within  the 
line  of  the  lashes  (blepharoplasty),  a  proceeding  which  at 
once  assists  the  restitution  of  the  displaced  lid,  and  gives 
protection  to  the  cornea  ;  the  lids  may  be  separated  a  few 
wrecks  later.  The  operation  for  the  cure  of  the  ectropion 
will  naturally  vary  with  the  seat,  extent,  and  cause  of  the 
deformity,  but  we  may  conveniently  distinguish  three  vari- 
eties of  organic  ectropion,  according  as  the  condition  has 
followed — (1)  a  wound  of  the  eyelid  with  faulty  union  ; 
(2)  a  deeply  adherent  scar  from  abscess,  disease  of  bone,  or 
deep  ulceration  of  the  lid  ;  or  (3)  extensive  scarring  of  the 
face  from  burns,  lupus,  etc.  When  the  cause  is  quite 
localized,  and  there  is  not  much  loss  of  tissue  (groups  1  and 
2),  the  scar  may  be  included  in  a  Y-shaped  incision,  the 
flap  separated  and  pushed  up  till  the  lid  is  in  position,  and 
the  lower  part  of  the  wound  then  brought  together  by  a  pin 
or  sutures,  so  that  what  was  a  v  now  becomes  a  y,  the 
edges  of  the  flap  being  attacked  by  sutures  to  the  limbs  of 
the  Y,  Fig.  131.     As  the  lid  has  generally  become  too  long, 

Fig.  131. 


V  Y  operation.     (From  Ritterich.) 

from  prolonged  eversion,  we  have  often,  at  the  same  time, 
to  shorten  it  by  removing  a  small  triangle  from  its  outer 
end,  and  uniting  the  edges  of  the  gap.  When  the  position 
of  the  deformity  prevents  the  above  operation  it  is  necessary 
to  introduce  new  skin  into  the  gap,  made  by  dissecting  out 


390  OPERATIONS. 

the  cicatricial  tissue  and  puttin^^  the  everted  lid  into  posi- 
tion. This  may  be  done  by  brinp:ing  a  flap  with  a  broad 
pedicle,  either  by  sliding  or  twisting,  into  the  gap;  or  by 
the  method  (introduced  into  our  country  by  Dr.  Wolfe)  of 
transplanting  from  a  distant  part  a  single  graft  of  skin  with- 
out a  pedicle,  large  enough  to  fill  the  gap  ;  or,  again,  by  fill- 
ing the  gap  with  several  small  pieces  of  skin  (dermic  grafts). 
Where  there  is  extensive  destruction  of  skin  (group  3) 
these  grafting  methods  seem  particularly  valuable.  If  a 
single  large  graft  be  used  the  important  points  are  to  make 
it  considerably  larger  than  the  deficiency  it  is  to  supply,  to 
free  the  under  surface  of  the  graft  very  thoroughly  of  all 
subcutaneous  tissue,  to  unite  it  by  numerous  fine  sutures, 
and  to  apply  warm  dressings.  The  single-graft  operation 
has  now  been  tried  many  times,  and  with  a  good  proportion 
of  successes. 

8.  Paralytic  and  congenital  ptosis  have  often  been  treated 
by  the  removal  of  an  oval  of  skin  from  the  upper  lid, 
parallel  to  its  length,  the  orbicularis  muscle  not  being 
touched.  This  simple  method,  however,  has  but  little 
effect,  unless  the  piece  removed  be  so  large  as  to  shorten 
the  lid  materially,  and  thus  endanger  the  power  of  com- 
plete closure.  More  complicated  operations,  intended  to 
raise  the  lid  by  producing  contraction  of  the  subcutaneous 
tissues,  or  adhesion  between  these  parts  and  the  tendon  of 
the  occipito-frontalis  at  the  eyebrow  without  the  removal 
of  any  skin,  have  been  recommended  by  Pagenstecher, 
Dransart,  Meyer,  and  Panas.  I  have  had,  and  have  seen 
in  the  hands  of  others,  satisfactory  results  from  Panas' 
operation  in  several  cases. 

9.  Canthoplasty,  for  lengthening  the  palpebral  fissure  at 
the  outer  cauthus.  The  canthus  is  divided  by  scissors  or  a 
knife  as  far  as  may  seem  necessary.  The  contiguous  ocular 
conjunctiva  is  then  slightly  dissected  up  and  attached  by 
sutures  to  the  cut  edges  of  the  skin,  so  as  to  prevent  re- 


OPERATIONS    Ox\     THE     EYELIDS 


891 


union,  one  suture  being  placed  in  the  angle  of  the  wound, 
one  above  and  one  below,  Fio^.  132. 


Fig.  133. 


Canthoplasty.     (From  Ritterich.) 

10.  Peritomy  for  obstinate  cases  of  partial  panuus. 
Anaesthesia  is  necessary.  Instruments:  Speculum,  Fig. 
139,  fixation  forceps,  Fig.  141,  scissors,  and  Beer's  kuife, 
Fig.  159.  With  the  knife  a  circular  incision  is  carried 
through  the  conjunctiva,  round  the  cornea,  at  5  mm.  (i'0> 
or  less,  from  its  border.  The  zone  of  conjunctiva  so  in- 
cluded, together  with  the  whole  of  its  subconjunctival  tissue 
down  to  the  sclerotic,  is  now  carefully  removed  by  the 
scissors.  The  bare  surface  thus  left  granulates,  and  finally 
contracts  to  a  narrow  band  of  white  scar-tissue,  by  which 
the  vessels  running  to  the  cornea  should  be  obliterated. 
The  subconjunctival  fascia  is  often  found  much  thickened 
in  these  cases.  Care  must  be  taken  not  to  make  the  inci- 
sion too  far  from  the  cornea,  lest  the  insertions  of  the  recti 
be  damaged.  The  strip  removed  should  extend  completely 
round  the  cornea ;  removal  of  only  a  part  of  the  zone  is  not 
satisfactory.  The  symptoms  are  generally  made  worse 
for  a  time,  and  the  final  result  is  not  reached  for  several 
months.  In  some  cases  the  operation  has,  in  my  experi- 
ence, been  very  successful,  whilst  in  others,  without  ap- 
parent reason,  it  has  quite  failed  of  its  purpose. 

Symblepharon,  adhesion  of  lid  to  globe  after  destruction 
of  conjunctiva,  unless  very  extensive,  can  be  greatly  im- 


392  OPERATIONS. 

proved  by  operation.  In  slight  canes  we  lia\  e  merely  to 
separate  the  adhesion  from  the  globe  and  bring  together 
the  edges  of  the  ocular  conjunctiva  to  cover  the  surface 
thus  exposed  and  thus  prevent  reunion.  But  when  the 
surface  exposed  by  the  dissection  is  large,  flaps  of  conjunc- 
tiva with  broad  pedicles  must  be  brought  down  to  cover 
the  deficiency  in  the  manner  first  proposed  by  Mr.  Teale  •/ 
or  mucous  membrane  may  be  transferred  from  the  lip  of 
the  patient  or  even  from  the  conjunctiva  of  a  rabbit. 
Snellen  has  lately  used  a  flap  of  neighboring  skin  with  a 
pedicle,  pushing  it  through  a  sort  of  buttonhole  in  the  lid 
and  attaching  it  in  the  gap  made  by  separating  the  adhe- 
sions. 

B.  Operations  on  the  Lachrymal  Apparatus. 

1.  Lachrymal  abscess.     (See  p.  101.) 

2.  Slitting  up  the  lower  canaliculus This  is  best  done 

by  means  of  a  knife  with  a  blunt  or  probe  point,  and  a 
blade  narrow  enough  to  enter  the  punctum.  The  best 
forms  of  these  knives  are  Weber's  knife,  with  a  probe  end, 
Fig.  134 ;  Bowman's,  with  nearly  parallel  borders  and  a 
rounded  end,  Fig.  1.S5,  and  Liebreich's,  Fig.  136.  Position 
as  for  1.  (I)  The  lower  lid  is  drawn  tightly  outward  and 
downward  by  the  thumb.  (2)  The  canaliculus  knife  is 
passed  vertically  into  the  punctum,  then  turned  horizon- 
tally and  passed  on  through  the  neck  of  the  canaliculus 
till  it  reaches  the  bony  (inner)  wall  of  the  lachrymal  sac. 
It  is  then  raised  up  from  heel  toward  point,  and  thus  made 
to  divide  the  canaliculus,  care  being  taken  that  the  neck 
is  freely  divided.  Liebreich's  knife  cuts  its  ow^n  way  with- 
out being  raised.  The  low^er  canaliculus  may  also  be  di- 
vided with  a  Beer's  knife,  Fig.  159,  which  is  run  along  a 

1  Teale,  Ophth.  Hosp.  Reports,  iii.  p.  253,  1861. 


OPERATIONS     ON     LACHRYMAL     APPARATUS.      393 

fine  grooved  director,  Fig.  133,  previously  introduced.  In 
cases  of  mucocele,  it  is  good  practice  to  divide  the  wall 
of  the  sac  freely,  and  some  surgeons  open  the  upper  as  well 
as  the  lower  canaliculus.  The  canaliculus  requires  to  be 
kept  open  every  three  or  four  days  till  its  cut 
edges  are  healed,  or  they  will  unite  again. 

3.  Probing  the   nasal    duct. — After  dividing 
the  canaliculus  pass  a  good-sized  lachrymal  probe 


Fig.  134. 

Weber's  canaliculus  kuile. 
Fig.  135. 

S!^ — ^ 


Bowmau's  canaliculus  knife. 
Fig.  136. 


3=^ 


Liebreich's  knife  for  canaliculus  and  nasal  duct. 

horizontally   along   its   floor    till   it  strikes   the 
inner,  bony,  wall  of  the  sac.     Then  raise  it  to  the 
vertical  position  and  push  it  steadily  down  the 
duct  (downward  and  a  very  little  outward  and 
backward)  till  the  floor  of  the  nose  is  reached. 
Bowman's  earlier  probes  were  in  six  sizes,  of 
which  the  largest  was  ^V  i'^ch  in  diameter.     Bow- 
man afterward  adopted  much  larger  probes  with 
bulbous  ends,  and  several  such  patterns  are  now  in  use. 
The  probe  used  should  be  the  largest  that  will  pass  easily. 
4.  A  stricture  of  the  duct  may  be  incised  with  any  of  the 
canaliculus  knives,  although  Weber's  and  Bowman's  are 

17* 


394  OPERATIONS. 

too  slender  to  be  used  with  safet3^  Liebreich's  is  intended 
to  be  so  used,  and  a  special  knife  for  the  purpose  had  pre- 
viously been  introduced  by  Stilling.  The  knife  is  used  as 
a  probe,  being  pushed  quite  down  the  duct,  then  partly 
withdrawn,  turned  in  another  direction,  and  pushed  down 
again.     There  is  generally  bleeding  from  the  nose. 

In  all  these  procedures  we  must  be  certain  that  the  probe 
or  knife  rests  against  the  bony  (nasal)  wall  of  the  lach- 
rymal sac  before  it  is  raised  into  the  vertical  direction.  If 
the  probe  be  stopped  at  the  entrance  of  the  canaliculus 
into  the  sac,  as  may  easily  happen  if  the  canal  be  not 
thoroughly  slit  in  its  whole  length,  the  lid  will  be  pulled 
upon  and  puckered  whenever  the  instrument  is  pushed 
toward  the  nose ;  but  if  the  probe  have  reached  the  sac, 
backward  and  forward  movements  will  not  usualh^  cause 
puckering  of  the  lid.  If  in  the  former  case  the  instrument 
be  turned  up  and  an  attempt  made  to  pass  it  down  the 
duct,  a  false  passage  will  probably  be  made. 

The  direction  of  the  two  nasal  ducts  is  either  parallel 
or  such  that  if  prolonged  upward  they  would  converge 
slightly;  they  very  seldom  diverge.  The  probe  when  in 
the  duct  should,  even  if,  as  usual,  its  lower  end  be  curved 
forward,  rest  against  and  indent  the  eyebrow  ;  if  it  stand 
forward  from  the  brow  it  is  usually  in  a  false  passage. 

Lachrymal  syringes  are  of  two  kinds :  (1 )  Anel's  syringe 
with  a  nozzle  fine  enough  to  pass  into  the  unopened  punc- 
tum,  Fig.  137.  By  injecting  a  little  water  into  the  duct 
through  the  canaliculus  we  can  sometimes  clear  out  slight, 
apparently  mucous,  obstruction  and  relieve  epiphora  with- 
out cutting  or  probing ;  and  by  the  same  method  we  can 
often  decide  whether  or  not  there  is  an  obstruction  needing 
the  severer  treatment.  (2)  Hollow  probes  attached  to 
syringes  of  various  patterns  are  used  for  passing  down  the 
duct  and  syringing  at  the  same  time.  Fig.  138  shows  a 
simple  form  sold  as  Bowman's. 


OPERATIONS  FOR  STRABISMUS 
Fig.  137.  Fig.  138. 


395 


wm 


I 


Anel's  syringe,  full  size. 


Bowman's  syringe,  about  half 
full  size. 


C.  Operations  for  Strabismus. 

Tenotomy. — The  object  is  to  divide  the  tendon  close  to 
its  insertion  into  the  sclerotic.  In  this  country  Critchett's 
subconjunctival  operation  is  commonly  used  ;  abroad  the 
operation  of  Yon  Graefe,  in  which  the  tendon  is  more  or 


396  OPERATIONS. 

loss  exposed,  is  more  often  employed.  The  internal  and 
external  recti  are  the  only  tendons  commonly  divided,  the 
internal  far  the  more  frequently.  Ana3sthesia  is  seldom 
necessary  except  for  young  children.  Instruments:  Stop 
speculum,  Fig.  139,  straight  scissors,  with  blunted  points, 
Fig.  140,  toothed  fixation  forceps,  Fig.  141,  strabismus  hook. 
Fig.  142.  There  are  several  forms  of  hook,  differing  in 
the  length  and  sharpness  of  the  curve  and  the  shape  of 
the  tip. 

Fig.  189. 


Stop  spring  speculum. 

Operations.  Graefe's. — An  incision  is  made  transversely 
over  the  insertion  of  the  tendon,  and,  the  conjunctiva  being 
pushed  aside.  Tenon's  capsule  is  opened  below  the  tendon  ; 
the  hook  is  then  passed  under  the  tendon,  and  the  latter 
divided  with  the  scissors.  The  whole  width  of  the  tendon 
is  exposed.  The  conjunctival  wound  may  be  closed  by  a 
single  stitch.  Snellen  makes  the  conjunctival  wound  paral- 
lel to  the  muscle  to  avoid  gaping.  The  effect  in  this  and 
all  operations  may  be  considerably  increased  if  the  various 
facial  or  indirect  connections  of  the  muscle  be  divided  as 
well  as  its  tendon.  This  is  done  (1 )  by  separating  the  con- 
junctiva from  the  fascia  and  its  muscle  by  a  burrowing  dissec- 
tion with  the  scissors  before  the  tendon  is  cut ;  (2)  by  freely 
dividing  the  fascia  above  and  below  the  tendon,  by  cutting 
with  the  scissors  upward  and  downward  after  having 
divided  the  tendon  itself;   (3)  by  tying  the  eve  out  with  a 


OPERATIONS  FOR  STRABISMUS 


39T 


silk  suture  passed  through  the  coujunctiva  and  surface 
fibres  of  the  sclerotic,  close  to  the  outer  border  of  the 
cornea,  and  attaching  it  to  the  temple  for  two  days  by 
strapping. 


398  OPERATIONS. 

Fig.  142. 


Strabismus  hook  (the  bent  part  is  represented  too  thin). 

CritcheW s  operation. — (1.)  Introduce  the  speculum,  and 
■with  the  fixation  forceps  in  the  left  hand,  pinch  up  a  fold 
of  conjunctiva  over  the  lower  border  of  the  tendon  (say  of 
the  rif^ht  internal  rectus)  at  its  insertion  ;  with  the  scissors 
in  the  right  hand  make  a  small  opening  close  to  the  end  of 
the  forceps,  and  parallel  with  the  border  of  the  tendon. 
The  exposed  fascia,  capsule  of  Tenon,  is  now  easily  recog- 
nized ;  it  is  to  be  pinched  up,  and  an  opening  made  in  it 
corresponding  to  the  conjunctival  wound.  By  taking  deep 
hold  with  the  forceps,  both  conjunctiva  and  fascia  may 
sometimes  be  divided  at  one  stroke.  As  a  rule,  both  con- 
junctiva and  Tenon's  capsule  are  thicker  in  children  than 
adults. 

(2.)  Take  the  hook  in  the  right  hand,  holding  the  wound 
open  with  the  forceps  in  the  left,  and  pass  it,  concavity 
downward  and  point  backward,  through  the  opening  in  the 
fascia  as  far  as  its  elbow,  keeping  its  end  alwa^'s  flat  against 
the  sclerotic.  Next  turn  the  end  of  the  hook  upward,  still 
guided  by  the  sclerotic,  between  the  tendon  and  the  globe, 
until  its  end  is  seen  projecting  beneath  the  conjunctiva 
above  the  upper  border  of  the  tendon.  On  now  attempt- 
ing to  draw  the  hook  toward  the  cornea  it  will  be  stopped 
by  the  tendon.  If  Tenon's  capsule  have  not  been  well 
opened,  the  hook  cannot  be  passed  beneath  the  tendon  nor 
swept  round  the  sclerotic. 

(3.)  Lay  down  the  forceps,  transfer  the  hook  to  the 
left  hand,  holding  its  handle  parallel  with  the  side  of  the 
nose  and  tightening  the  tendon  by  traction  forward  and 
outward  ;  pass  the  scissors,  with  the  blades  slightly  opened, 


OPERATIONS     FOR     STRABISMUS.  399 

into  the  wound,  and  push  them  stvuightui)  between  theliook 
and  the  eye;  the  tendon  is  divided  at  two  or  three  snips 
with  a  crisp  sound  and  feelin,<r.  When  the  whole  breadth 
of  the  tendon  is  divided  the  hook  slips  forward  beneath 
the  conjunctiva  up  to  the  ed.g'e  of  the  cornea.  It  is  well, 
by  reintroducing-  the  hook,  to  make  sure  that  no  small 
strands  of  the  tendon  have  escaped,  for  the  operation  does 
not  succeed  unless  the  division  be  complete. 

No  after-treatment  is  needed,  but  the  patient  is  more 
comfortable  if  the  eye  be  tied  up  for  a  few  hours. 

The  difficulties  for  beginners  are:  (1)  to  be  sure  of 
opening  the  fascia ;  (2)  to  avoid  pushing  the  tendon  in 
front  of  the  scissors,  especially  when  only  the  upper  part 
remains  undivided. 

Simple  division  of  one  internal  rectus  without  separation 
and  division  of  fascia  diminishes  the  squint  by  about  two 
lines  (4  mm.).  The  effect,  however,  is  often  much  less  if 
the  patient  be  adult  or  nearly  so. 

Liebreich^s  operation  is  Critchett's  with  the  addition  of 
the  separation  of  the  conjunctiva  from  the  fascia  and  divi- 
sion of  the  fascia  beyond  the  edges  of  the  tendon  described 
at  p.  398.  These  additions  to  simple  tenotomy  can  be  more 
easily  and  thoroughly  applied  to  Graefe's  operation  when 
the  incision  is  over  the  tendon,  and  after  a  considerable 
trial  I  have  ceased  to  use  Liebreich's  method.  In  any 
case  of  considerable  convergent  squint  or  squint  operated 
on  in  an  adolescent  or  adult  I  prefer  Graefe's  method, 
which  admits  of  the  maximum  effect  being  easily  ob- 
tained. 

The  immediate  effect  of  the  tenotomy  of  a  rectus  muscle 
is  lessened  after  a  few  days  by  the  reunion  of  the  tendon 
with  the  sclerotic,  but  after  a  few  weeks  or  months  it  is 
sometimes  again  increased  by  the  stretching  of  this  new 
tissue. 

Readjustment  or  Advancement  consists  in  bringing  for- 


400  OPERATIONS. 

ward  to  a  new  attachment  the  tendon  of  a  rectus,  generally 
the  internal,  which  has  become  attached  too  far  back  after 
a  previous  tenotomy,  or  is  acting  inefficiently,  as  in  various 
cases  of  primary  divergent  squint;  advancement  of  the 
external  rectus  is  also  used  in  simultaneous  conjunction 
with  tenotomy  of  the  internal  in  high  degrees  of  conver- 
gent squint,  especially  when  the  squint  is  of  many  years' 
duration.  Indeed,  whether  performed  for  divergent  or 
convergent  strabismus,  tenotomy  of  the  opponent  muscle  is 
generally  needed.  There  are  several  different  operations, 
but  in  all  of  them  the  tendon  is  held  in  its  new  position  by 
sutures.  The  operation  is  tedious,  but  may  often  be  done 
under  cocaine.  Instruments  are  the  same  as  for  tenotomy. 
I  now  generally  perform  the  operation  as  follows  (essen- 
tially the  method  described  by  Tweedy') :  (1)  A  stitch  of 
fine  silk  is  first  put  through  conjunctiva  and  surface  fibres 
of  sclerotic,  close  to  the  inner  edge  of  cornea,  and  exactly 
on  the  horizontal  line ;  this  is  to  serve  as  a  guide  in  case 
the  eyeball  rotates  afterward.  (2)  The  tendon  is  exposed 
by  a  vertical  wound  in  the  conjunctiva  about  5  mm.  from 
the  corneal  border,  the  fascia  opened  above  and  below,  and 
a  hook  passed  under  the  tendon.  (3)  A  stitch  is  passed 
through  the  upper  part  of  the  muscle  alone,  not  including 
conjunctiva,  some  way  from  its  attachment,  and  tied  round 
the  included  part  of  the  muscle,  and  the  needle  then  passed 
beneath  conjunctiva  and  fascia  and  brought  out  above  the 
upper  edge  of  the  cornea ;  the  lower  part  of  the  muscle  is 
treated  in  the  same  way,  and  the  tendon  then  divided  from 
the  sclerotic  with  scissors,  and,  if  thought  necessary,  short- 
ened by  cutting  off  the  portion  in  front  of  the  sutures.  The 
needle  carrying  the  central  (guide)  thread  is  now  passed 
from  behind  forward  through  the  muscle  between  the  other 
two  sutures  and  overlying  conjunctiva,  and  tied.  The  upper 

»  Tweedy,  Lancet,  March  22,  18S4. 


EXCISION     OF     THE     EYE.  401 

and  lower  stitches  are  then  tied  slightly.  The  conjunctiva 
is  a  good  deal  dragged  upon  above  and  below,  but  soon 
stretches,  or  the  sutures  partly  cut  through.  The  opponent 
rectus  is  divided  before  the  sutures  are  tied.  The  eyes 
should  both  usually  be  kept  quietly  tied  up  for  several 
days,  and  the  stitches  be  left  in  for  a  week,  or  until  they 
come  away,  if  silk. 

De  Wecker's  method  of  advancement  by  folding  the 
tendon  on  itself,  so-called  advancement  of  Tenon's  capsule, 
does  not  seem  to  have  gained  general  acceptance,  and  need 
not  be  described  here.  I  have  had  very  good  success  with 
it  once  or  twice. 

D.  Excision  of  the  Eye. 

Instruments  as  for  squint,  but  the  scissors  curved  on  the 
flat.  The  operator  may  stand  either  behind  or  in  front. 
(1)  Divide  the  ocular  conjunctiva  all  round,  close  to  the 
cornea.  (2)  Open  Tenon's  capsule,  and  divide  each  rectus 
tendon  and  the  neighboring  fascia  on  the  hook;  the  two 
obliques  are  seldom  divided  on  the  hook.  (3)  Make  the 
eye  start  forward  by  pressing  the  speculum  back  behind 
the  equator  of  the  globe.  (4)  Pass  the  scissors  backward 
along  the  sclerotic  until  their  open  blades  can  be  felt  to 
embrace  the  optic  nerve,  recognized  by  its  toughness  and 
thickness,  and  divide  it  by  a  single  cut,  while  steadying  the 
globe  with  a  finger  of  the  other  hand.  Finish  by  dividing 
the  oblique  muscles  and  remaining  soft  parts,  close  to  the 
globe.  Apply  pressure  for  a  minute  or  tw^o,  and  then 
tie  up  tightly  for  six  or  eight  hours  with  an  elastic  pad  of 
small  sponges  overlaid  by  cotton  wool.  There  is  scarcely 
ever  serious  bleeding.  The  artificial  eye  may  be  fitted  in 
from  three  to  four  weeks. ^ 

1  The  glass  eye  must  be  renewed  as  often  as  it  gets  rough,  generally 
at  least  once  a  year.     Some  persons  have  much  difficulty  in  tolerating 


402  OPERATIONS. 

After  some  weeks  or  months  a  button  of  granulation 
tissue  occasionally  grows  from  a  scar  at  the  bottom  of  the 
conjunctival  sac,  and  should  be  snipped  off. 

The  operation  is  more  difficult  when  the  eye  is  ruptured 
or  shrunken,  or  the  surrounding-  parts  much  inflamed  and 
adherent.  The  order  of  division  of  the  muscles  is  imma- 
terial. The  important  points  are  to  leave  as  much  con- 
junctiva as  possible,  so  as  to  form  a  deep  bed  for  the  glass 
eye,  and  by  keeping  the  scissors  close  to  the  globe  during 
the  whole  operation,  to  avoid  unnecessary  laceration  of  the 
tissues. 

When,  as  in  some  cases  of  intra-ocular  tumor,  it  is  desired 
to  remove  another  piece  of  the  optic  nerve,  the  nerve  should 
be  felt  for  with  the  finger,  seized  and  drawn  forward  with 
the  forceps,  and  cut  off  further  back  with  the  scissors. 

Substitutes  for  excision  of  the  eyeball. — Abscission  is  the  re- 
moval of  a  staphj'ioinatous  cornea  with  the  front  part  of  the 
sclerotic,  leaving  the  hinder  part  of  the  globe,  with  the 
muscles  attached,  to  serve  as  a  movable  stump  for  carrying 
the  artificial  eye.  Four  or  five  semicircular  needles  carrying 
sutures  are  made  to  puncture  and  counter-puncture  the  scler- 
otic, just  in  front  of  the  attachments  of  the  recti ;  the  part  of 
the  globe  in  front  of  the  needles  is  cut  off,  the  needles  drawn 
through,  and  the  sutures  tied.  The  operation  is  admissible 
only  when  the  ciliary  region  is  free  from  disease,  and  has  there- 
fore a  very  limited  application ;  even  in  the  most  favorable 
cases  the  stump  is  not  entirely  free  from  the  risk  of  setting  up 
sympathetic  inttammation,  and  I  therefore  never  perform  it. 
It  is  said  that  if  the  sutures  are  passed  only  through  the  con- 
junctiva or  the  muscles,  the  risk  is  less  than  when  they  are 
passed  through  the  sclerotic. 

The  operation  of  optico-ciliary  neurotomy,  in  which  the  optic 
nerve  and  all  the  ciliary  nerves  are  divided  without  removal  of 
the  globe,  with  the  view  of  preventing  sympathetic  disease,  ap- 
pears to  me  to  be  bad  surgery.     The  sensibility  of  the  cornea, 

it,  and  they  must  be  content  to  wear  it  for  only  a  part  of  the  day.    It  is 
always  to  be  removed  at  bedtime. 


EXCISION     OF     THE     EYE.  403 

abolished  by  the  operation,  often  returns,  proving  that  the 
ciUary  nerves  have  reunited.  The  cut  ends  of  the  optic  nerve 
have  also  been  found  reunited,  and  though  union  may  be  pre- 
vented by  exsection  of  a  considerable  piece  of  the  optic  nerve, 
the  same  cannot  be  done  with  the  ciliary  nerves.  The  opera- 
tion, therefore,  cannot  be  relied  upon  to  destroy  these,  nor,  it 
may  be  added,  any  of  the  other  possible  paths  along  which 
sympathetic  irritation  and  inflammation  ma}^  travel ;  indeed, 
sympathetic  inflammation  has  been  observed  to  follow  the 
operation  in  at  least  one  case. 

Evisceration  of  the  eye,  long  ago  performed  in  certain  cases 
by  sundry  operators,  has  been  systematically  practised  and  ad- 
vocated lately  by  Mr.  Mules, ^  of  Manchester,  and  Professor 
Graefe,  of  Halle.  The  front  of  the  eye  is  removed  at  the  sclero- 
corneal  junction,  and  the  whole  contents  of  the  globe  emptied 
out  with  any  convenient  instrument,  very  great  care  being 
taken  to  remove  every  trace  of  choroid  and  ciliary  body.  Mr. 
Mules  then,  after  enlarging  the  scleral  opening  by  a  vertical 
slit,  introduces  into  its  cavity  a  hermetically  closed,  hollow 
glass  ball,  and  stitches  the  sclerotic  carefully  over  it  with  fine 
catgut,  the  conj uncti va  being  separately  sewn  afterward.  The 
parts  should  be  irrigated  or  sprayed  during  the  whole  opera- 
tion. There  is  more  reaction  than  after  excision,  and  if  the 
sclerotic  be  much  inflamed,  or  if  suppuration  occur,  the  stitches 
may  give  way.  The  introduction  of  the  glass  globe  is  not  an 
essential  part  of  the  proceeding,  its  object  being  merely  to  im- 
prove the  stump.  Graefe  advocates  evisceration  as  less  likely 
than  excision  to  be  followed  by  meningitis— a  terrible  accident, 
which  ever}^  now  and  then  occurs.^  Mules  defends  it  as  likely 
to  be,  equally  with  excision,  a  safeguard  against  sympathetic 
disease  whilst  allowing  a  better  stump  for  the  artificial  eye. 

Mr.  Frost, ^  wishing,  in  common  with  many  others  in  the 
present  imperfect  state  of  our  knowledge  of  sympathetic  in- 

1  Mules,  Trans.  Ophth.  Soc,  v.  200,  1885. 

2  The  known  cases  of  meningitis  after  excision,  about  thirty-five  in 
number,  are  collected  in  a  paper  by  the  author  in  vol.  vi.  of  the  Ophth. 
Soc.  Transactions,  1886. 

3  Frost,  Brit.  Med.  Assoc,  Brighton  Meeting,  1886. 


404  OPERATIONS. 

flammation,  to  get  rid  of  all  properly  ocular  tissue,  proposes 
the  introduction  of  Mules's  glass  globe  into  the  cavity  of 
Tenon's  capsule,  uniting  the  muscles  and  conjunctiva  over  it. 
The  operation  of  stretching  the  infra-trochlear,  or  external 
nasal  nerve,  has  been  introduced  by  Dr.  Badal,  as  an  alterna- 
tive to  excision  for  the  relief  of  pain,  e.g.^  in  absolute  glaucoma. 
The  nerve — or  nerves,  for  there  are  two  or  three  twigs— is 
found  by  making  a  nearly  vertical  incision  through  skin  and 
orbicularis  muscle,  rather  below  and  external  to  the  inner 
end  of  the  eyebrow. 

E.     Operations  on  the  Cornea. 

1.  Removal  of  foreign  bodies. — Instruments:  A  steel 
spud,  Fig.  143,  or  a  broad  needle  with  double  cutting  edge, 
Fig.  144.     A  2  per  cent,  solution  of  cocaine  is  to  be  dropped 

Fig.  143.  Fig.  144. 


Corneal  spud.  Broad  needle. 

in  two  or  three  times  within  five  minutes.  The  operator 
stands  behind  the  patient,  and,  keeping  the  lids  apart  with 
his  index  and  ring  fingers,  steadies  the  eyeball  by  placing 
his  middle  finger  against  its  outer  or  inner  side.  The 
chip  is  gently  picked  or  tilted  off  by  placing  the  edge  of 
the  spud  beneath  it,  or,  if  firmly  embedded,  a  certain 
amount  of  scraping  may  be  necessary.  If  the  foreign  body 
be  barely  embedded  in  the  epithelium,  a  touch  with  a  little 
roll  of  blotting-paper  wall  often  detach  it.  When  a  frag- 
ment of  iron  has  been  present  for  more  than  a  couple  of 
days  its  corneal  bed  is  usually  stained  by  rust,  and  a  little 
plate  or  ring  of  brown  corneal  slough  can  often  be  picked 
off  after  the  removal  of  the  chip  ;  but,  as  a  rule,  this 
minute  slough  may  be  left  to  separate  spontaneously. 

1  Badal,  Bull,  de   la   Soc.  de  Chir.,  Dec.   1882;    Lagrange,  Arch. 
d'Ophthal.,  vi.  43,  1886. 


OPERATIONS  ON  THE  CORNEA.       405 

After-treatment. — Tie  the  eye  up,  so  as  to  protect 
the  corneal  surface  from  friction  and  irritation.  Atropine 
is  to  be  used  if  there  be  marked  congestion  and  photo- 
phobia. 

When  a  splinter  is  deeply  and  firmly  embedded,  especi- 
ally if  it  have  penetrated  the  cornea  and  is  projecting  into 
the  anterior  chamber,  its  removal  is  often  very  difficult. 

Unless  great  care  be  taken  the  splinter  in  such  a  case 
may  be  pushed  on  into  the  chamber,  and  the  iris  or  lens 
be  wounded.  This  may  sometimes  be  prevented  by  pass- 
ing a  broad  needle  through  the  cornea  at  another  part,  and 
laying  it  against  the  inner  surface  of  the  wound,  so  as  to 
form  a  guard  or  foil  to  the  foreign  body,  the  latter  being 
removed  by  spud  or  forceps  from  the  front. 

A  foreign  body  in  the  anterior  chamber  should,  in  recent 
cases,  always  be  removed,  and  the  piece  of  iris  on  which 
it  lies  must  generally  be  excised.  In  cases  of  old  standing 
we  may  judge  by  the  symptoms  whether  to  operate  or  not. 

2,  Paracentesis  of  the  anterior  chamber.— Position  as 
for  1,  or  recumbent ;  general  anaesthesia  not  necessary. 
Instruments:  A  paracentesis  needle.  Fig.  145,  with  a  very 
small,  short,  triangular  blade,  bent  at  an  obtuse  angle,  like 
a  minute  bent  keratome ;  or  a  broad  needle,  Fig.  144. 
The  former  is  more  safe,  as  the  blade  is  too  short  to  reach 
the  iris  or  lens,  even  if  the  patient  should  jerk  his  head. 
If  the  contents  of  the  chamber  do  not  follow  the  needle  on 
its  withdrawal,  a  small  probe.  Fig.  145,  is  passed  into  the 

Fig.  145. 


;©S:=^= 


Paracentesis  needle  and  probe  mounted  on  same  handle. 

wound.     In  cases  where  the  operation    needs   repeating 
every  day  or  two,  the  original  wound  can  generally  be 


406  OPERATIONS. 

reopened  with  a  probe.      Speculum  and  fixation  forceps 
should  be  used,  unless  the  patient  has  good  self-control. 

3.  Corneal  section  for  hypopyon  ulcer Position  recum- 
bent ;  general  ansesthesia  seldom  needed.  Instruments:  A 
Graefe's  or  Beer's  cataract  knife,  Figs.  153  and  159,  specu- 
lum, and  fixation  forceps.  The  incision  is  carried  through 
the  whole  thickness  of  the  cornea  from  one  side  of  the 
ulcer  to  the  other,  being  both  begun  and  finished  in  sound 
tissue.  Or  it  may  be  placed  entirely  in  sound  cornea,  or 
at  the  sclero-corneal  junction,  leaving  the  ulcer  untouched ; 
the  last  position  avoids  all  risk  of  wounding  the  lens. 

The  knife  is  entered  at  an  angle  with  the  plane  of  the 
iris,  its  edge  straight  forward;  when  its  point  is  seen,  or 
judged  to  have  perforated  the  cornea,  the  handle  is  de- 
pressed until  the  back  of  the  knife  lies  parallel  with  the 
iris,  and  the  blade  then  pushed  straight  across  the  ulcer  to 
the  point  chosen  for  counter-puncture  ;  often  in  practice  it 
is  simply  pushed  on  till  it  cuts  out.  The  aqueous  ought 
not  to  escape  until  the  point  of  the  knife  is  engaged  in  its 
counter-puncture,  but  an  earlier  escape  cannot  always  be 
avoided.  If  it  be  desired  to  keep  the  wound  open,  its 
edges  are  to  be  separated  by  a  probe  every  second  or  third 
day.  The  wound  closes  quickly  at  first,  unless  kept  open, 
but  after  having  been  opened  a  few  times,  it  sometimes  re- 
mains patent  for  longer. 

4.  Cauterization  of  the  cornea  is  best  performed  with  a 
very  fine  galvano-caustic  terminal,  which  should  be  very 
intensely  hot — yellow  or  almost  white  heat.  The  finest 
terminal  of  Paquelin's  instrument  may  be  used,  but  its 
action  cannot  be  so  well  localized,  owing  to  the  greater 
bulk  of  the  heated  metal.  If  the  eye  be  much  congested 
I  generally  apply  solid  cocaine  hydrochlorate  to  the  part 
to  be  burnt,  and  to  the  part  where  the  fixation  forceps  will 
be  applied. 


OPERATIONS  ON  THE  CORNEA.       40Y 

Operations  for  conical  cornea. — The  object  is  to  produce 
a  scar  at  the  apex  of  the  cone,  which  by  contracting  shall 
reduce  the  curvature,  and  so  diminish  the  high  degree  of 
irregular  myopic  astigmatism  to  which  the  condition  gives 
rise. 

There  are  several  methods.  (1.)  Graefe's  treatment  con- 
sisted in  first  carefully  shaving  off  the  apex  of  the  cone, 
w^ithout  entering  the  anterior  chamber,  and  then  producing 
an  ulcer  by  touching  the  raw  surface  with  solid  mitigated 
nitrate  of  silver  (F.  1),  and  so  obtaining  a  scar.  This 
method  is  more  painful  and  less  safe  than  others,  and  is 
now  seldom  used.  (2.)  In  another  operation  the  apex  of 
the  cone  is  cut  off  with  a  cataract  knife,  the  anterior 
chamber  being  entered,  and  the  wound  either  left  to  close 
or  united  by  sutures ;  there  are  several  different  modes  of 
removing  the  little  piece.  (3.)  Sir  William  Bowman  re- 
moves the  outer  layers  of  the  cone  by  means  of  a  very  deli- 
cate cutting  trephine,  and  leaves  the  surface  to  heal  and 
contract.  (4.)  The  galvanic  cautery  is  now  being  a  good 
deal  used  instead  of  the  knife  or  trephine ;  I  have  found 
that  the  opacity  left  by  the  cautery  is  apt  to  engage  a  larger 
area  than  that  caused  by  cutting  operations,  but  more  ex- 
perience is  needed  before  deciding  on  the  relative  merits  of 
Nos.  2  and  4. 

After-treatment. — Atropine  and  compressive  bandage 
until  the  wound  has  closed;  antiphlogistic  treatment,  and 
heat  locally,  if  inflammatory  symptoms  arise. 

All  operations  for  conical  cornea  are  difficult  to  perform 
and  somewhat  uncertain  in  result,  but  in  many  cases  vision 
improves,  from  barely  seeing  very  large  letters  before 
operation  to  reading  small  print  afterward.  The  final 
result  is  never  gained  for  several  months.  An  artificial 
pupil  may  be  necessary  if  a  large  corneal  opacity  finally 
remain. 


408  OPERATIONS. 


F.     Operations  on  the  Iris. 


A  portion  of  the  iris  is  very  often  removed  by  operation 
(iridectomy),  and  with  various  objects.  The  principal  of 
these  are  :  (1)  the  direct  improvement  of  sight  by  altering 
the  position  and  size  of  the  pupil  (artificial  pupil)  ;  (2)  to 
influence  the  course  of  an  active  disease — glaucoma,  iritis, 
ulcer  of  cornea  with  hypopyon  ;  (3)  to  remove  the  risks 
attending  "  exclusion  "  and  "  occlusion  "  of  the  pupil,  by 
restoring  communication  between.the  anterior  and  posterior 
chambers;  (4)  as  a  stage  in  the  extraction  of  cataract. 

Iridectomy  often  causes  astigmatism  by  giving  rise  to  flatten- 
ing of  that  meridian  of  the  cornea  which  forms  a  right  angle 
with  the  operation  wound,  and  by  bringing  the  edge  of  the 
cornea  and  lens  into  use  permits  the  spherical  aberration  (Fig. 
9)  which  the  iris  naturally  prevents  ;  striae,  if  present  in  the 
lens,  add  to  these  ditticulties,  all  of  which  are,  cmter is  paribus^ 
greater  if  the  artificial  pupil  be  large  and  uncovered  by  the 
upper  lid.  Thus  it  is  evident  that  an  artificial  pupil  should 
seldom  be  made  for  the  optical  improvement  of  sight  unless 
the  opacity  in  or  over  the  natural  pupil  be  such  as  to  interfere 
seriously  with  visual  acuteness. 

Artificial  pupil. — The  object  is  to  remove  the  portion  of 
iris  in  the  position  best  adapted  to  sight ;  thus,  in  cases  of 
leucoma  the  iridectomy  is  made  opposite  the  clearest  part 
of  the  cornea.  When  the  state  of  the  cornea  allows  it,  the 
new  pupil  should  be  made  down-in  ward  or  straight  down- 
ward ;  the  next  best  place  is  outward  or  out-upward ;  and 
straight  upw^ard  is,  of  course,  least  useful,  because  the  new 
pupil  will  be  covered  by  the  lid.  The  coloboma  should 
generally  be  small,  and  often  only  the  inner  (pupillary) 
part  of  the  chosen  portion  is  to  be  removed,  the  outer  (cili- 
ary) part  being  left.  Fig.  140,  so  as  to  prevent  the  light 
passing  through  the  margin  of  the  lens.  After  suc^  an 
operation  the  pupil  will  be  oval  or  pedr-shaped,  and  widest 


OPERATIONS     ON     THE     IRIS.  409 

towards  the  centre.  The  incision  should  lie  in  the  corneal 
tissue,  if  only  the  pupillary  part  of  the  iris  is  to  be  removed ; 
but  if  only  a  narrow  zone  of  cornea  remain  clear  the  in- 
cision must  lie  a  little  outside  the  sclero-corneal  junction, 

Fig.  U6. 


Iridectomy  downward  and  inward  for  artificial  pupil. 

lest  its  scar  should  interfere  with  the  transparency  of  the 
remaining  clear  cornea.  The  loop  of  iris  should  be  cut  off 
with  a  single  snip. 

In  iridectomy  for  glaucoma  the  coloboma  is  to  be  large, 
the  iris  to  be  removed  quite  up  to  its  ciliary  attachment, 
and  the  incision  to  lie  as  far  back  in  the  sclerotic  as  possi- 
ble, 1  to  2  mm.  from  the  border  of  the  cornea  is  not  too 
far.  The  coloboma  should  be  wider  towards  the  wound 
than  towards  the  pupil,  so  as  to  form  a  "  keyhole  pupil," 
Fig.  147.     The  loop  of  iris,  when  drawn  out,  is  usually 

Fig.  147. 


Iridectomy  for  glaucoma.     (De  "Wecker.) 

cut  first  in  one  angle  of  the  wound,  then  torn  from  its  cili- 
ary attachment  by  carefully  drawing  it  over  to  the  other 
angle  of  the  wound,  and  its  other  end  cut  there. 

The  difficulty  of  making  an  artificial  pupil,  for  optical 
purposes,  of  the  best  shape,  i.  e.,  broad  towards  the  natural 
pupil  and  narrow  towards  the  circumference,  is,  owing  to 

18 


410 


OPERATIONS. 


the  small  size  of  the  parts,  much  greater  than  would  be  at 
first  supposed,  and  several  methods  are  in  use      In  Mr. 
Critchett's  iridodesis  a  loop  of  iris  is 
Fig.  148.  drawn  out,  and  strangulated  by  a  fine 

ligature  tied  round  it  over  the  incision ; 
the  little  loop  soon  drops  oS",  and  the 
result  is  a  pear-shaped  pupil,  with  its 
broad  end  towards  the  centre.  Irrita- 
tion, and  even  destructive  irido-cycli- 
tis,  sometimes  follow^  and  the  operation 
has  therefore  been  abandoned.  An- 
other plan  is  to  draw  out  a  small  loop 
of  iris  with  a  blunt  hook  (Tyrrell's 
hook),  and  to  cut  off"  only  the  pupillary 
portion;  this  method  is  uncertain,  but, 
on  the  whole,  it  gives  good  results. 

Iridotomy  (iritomy). — In  this  ope- 
ration an  artificial  pupil  is  formed  by 
the  natural  gaping  of  a  simple  incision 
in  the  iris.  It  is  only  applicable  when 
the  lens  is  absent.  Through  a  small 
incision  in  the  cornea,  between  the 
centre  and  margin,  the  scissors  (shears) 
shown  at  Fig.  148  are  passed ;  the  more 
pointed  blade  is  passed  behind  the  iris 
as  far  as  is  deemed  necessary,  and  the 
iris  and  false  membrane  divided  by  a 
single  closure  of  the  blades.  It  is  some- 
times necessary  to  make  a  second  cut 
at  an  angle  with  the  first,,  so  as  to  in- 
Iridotomy  scissors,     elude  a  Y-shaped  tongue  of  iris  which 

will  shrink  and  allow  a  larger  pupil. 
Iridotomy  is  most  useful  when  the  iris  has  become  tightly 
drawn  towards  the  operation  scar  by  iritis  occurring  after 
cataract  extraction,  Fig.  100.     The  line  of  the  cut  in  the 


OPERATIONS    ON    THE     IRIS.  411 

iris  should  lie,  as  nearly  as  may  be,  across  the  direction  of 
its  fibres,  and  should  always  be  as  long  as  possible.  In 
cases  of  this  sort,  or  when,  even  without  such  dragging  of 
the  iris  towards  the  scar,  the  pupil  is  filled  w^ith  iritic  or 
cyclitic  membrane  after  cataract  extraction,  iridotomy 
yields  a  better  pupil  than  iridectomy,  and  with  less  dis- 
turbance of,  and  no  dragging  upon,  the  ciliary  body. 

The  Operation  of  Iridectomy. — Position  recumbent ; 
the  operator  usually  stands  behind.  Anaesthesia  is  often 
advisable,  but  many  operators  prefer  cocaine ;  I  myself 
prefer  general  anaesthesia  whenever  the  operation  is  critical 
or  likely  to  be  difficult.  Instruments  :  stop  speculum,  Fig. 
139,  fixation  forceps,  bent  keratome.  Fig.  149,  iris  forceps, 
bent  at  various  angles  according  to  the  position  of  the  iri- 
dectomy. Fig.  151,  iris  scissors  with  elbow  bend.  Fig.  151, 
of  W'hich  some  patterns  have  one  or  both  blades  probe- 
pointed,  a  curette,  Fig.  155,  or  small  vulcanite  or  tor- 
toise-shell spatula  for  replacing  the  cut  ends  of  the  iris, 
and  preventing  their  incarceration  in  the  angles  of  the 
wound.  The  iridotomy  scissors,  Fig.  148,  are  very  con- 
venient, especially  for  downward  and  inward  operations, 

Fig.  149. 


Bent  triangular  keratome. 

and  for  the  left  hand.  Some  operators  prefer  Graefe's 
cataract  knife.  Fig.  153,  to  the  triangular  keratome,  in 
iridectomy  for  glaucoma. 

The  conjunctiva  is  held  by  the  fixation  forceps  near  the 
cornea,  at  a  point  opposite  to  the  place  selected  for  punc- 
ture. (I)  The  keratome  is  to  be  entered  slowly,  steadily 
pushed  on  across  the  anterior  chamber  till  the  wound  is  of 
the  desired  size,  then  slowly  withdrawn, and,  in  withdrawal, 


412 


OPERATIONS. 


its  blade  carefully  turned  to  one  side,  so  as  to  lengthen  the 
internal  wound.  Two  points  need  attention:  as  soon  as 
the  point  of  the  knife  is  visible  in  the  anterior  chamber,  it 


Fig.  150. 


Fig.  151. 


Iridectomy  scissors. 


Iris  forceps. 


must  be  tilted  slightly  forward  to  avoid  wounding  the 
iris  and  lens ;  and  care  must  be  taken  not  to  tilt  it  side- 
wavs,  for  if  this  be  done  the  wound,  instead  of  lying  paral- 


OPERATIONS     ON     THE     IRIS.  413 

lei  with  the  border  of  the  cornea,  will  lie  more  or  less  across 
that  line.  The  incision  is  made  almost  as  much  by  lifting 
the  eye  against  the  knife  with  the  fixation  forceps,  as  by 
pushing  the  knife  against  the  eye.  The  forceps  are  now 
laid  down,  or,  if  fixation  be  still  necessary,  they  are  given 
to  an  assistant,  who  is  gently  to  draw  the  eye  into  the  posi- 
tion required  for  the  next  step  ;  in  so  doing  he  is  to  draw 
away  from  the  eye,  not  to  push  the  ends  of  the  forceps 
against  the  sclerotic.  (2)  The  iris  forceps  are  introduced, 
closed,  into  the  wound,  and  passed  very  nearly  to  the  pupil- 
lary border  of  the  iris,  before  being  opened  and  made  to 
grasp  it.  By  seizing  the  pupillary  part  of  the  iris  its  inner 
circle  is  certain  to  be  brought  outside  the  wound,  when  the 
forceps  are  now  withdrawn ;  if  the  iris  be  seized  in  the 
middle  of  its  breadth,  a  buttonhole  may  be  cut  out,  and 
the  pupillary  part  left  standing.  Often  the  iris  is  carried 
into  the  wound  by  the  gush  of  aciueous  as  the  keratome  is 
withdrawn,  and  it  it;  then  seized  without  passing  the  forceps 
so  far  into  the  chamber.  (3;  The  loop  of  iris  having  been 
cut  off,  either  at  a  single  snip,  or  by  cutting  first  one  end 
and  then  the  other,  as  in  glaucoma,  the  tip  of  the  curette 
or  spatula  is  passed  into  each  angle  of  the  vround  to  free 
the  iris,  should  it  be  entangled ;  it  is  important  to  make 
sure  that  no  iris  is  left  incarcerated  in  the  track  of  the 
wound.  The  speculum  is  now  removed,  and  the  eye,  or 
both  eyes,  bandaged  over  a  pad  of  cotton-wool,  either  with 
a  four-tailed  bandage  of  knitted  cotton,  or  two  or  three 
turns  of  a  soft  cotton  or  flannel  roller. 

The  anterior  chamber  is  refilled  in  twenty-four  hours, 
except  in  cases  of  glaucoma,  when  the  wound  frequently 
leaks  more  or  less  for  several  days.  It  is  as  well  in  all 
cases  to  keep  the  eye  bandaged  for  a  week,  the  wound  being 
but  feebly  united  and  likely  to  give  way  from  any  slight 
blow  or  other  accident.  When  the  incision  lies  in  or 
partly  in  the  sclerotic,  some    bleeding  generally  occurs  ; 


414  OPERATIONS. 

when  the  eye  is  much  congested  this  hemorrhage  is  consid- 
erable, and  the  blood  may  run  into  the  anterior  chamber 
either  during  or  after  the  excision  of  the  iris ;  it  can  be 
drawn  out  by  depressing  the  lip  of  the  wound  with  the 
curette,  but  if  the  chamber  again  fills  no  prolonged  efforts 
need  be  made,  since  the  blood  is  usually  absorbed  without 
trouble  in  a  few  days.  In  diseased,  especially  glaucoma- 
tous eyes,  however,  its  absorption  is  often  slow.  Secondary 
hemorrhage  sometimes  occurs  from  a  diseased  iris  several 
days  after  the  operation. 

Sclerotomy  is  an  operation  for  dividing  the  sclerotic  near 
to  the  margin  of  the  cornea.  It  is  employed  in  glaucoma 
instead  of  iridectom}^,  or  after  iridectomy  has  failed.  The 
pupil  is  to  be  contracted  as  much  as  possible  by  eserine 
before  the  operation.  It  is  often  performed  subconjunc- 
tivally,  a  Graefe's  cataract  knife,  Fig.  153,  being  entered 
through  the  sclerotic  near  the  margin  of  the  cornea,* 
passed  in  front  of  the  iris,  and  brought  out  at  a  corre- 
sponding point  on  the  other  side,  so  as  to  include  nearly 
one-third  of  the  circumference  ;  the  puncture  and  counter- 
puncture  are  then  enlarged  by  slow  sawing  movements; 
the  central  quarter  of  the  sclerotic  flap  and  the  whole  of 
the  conjunctiva,  except  at  the  punctures,  are  left  undivided. 
The  knife  is  then  slowly  withdrawn.  The  whole  operation 
is  to  be  done  very  slowly,  that  the  aqueous  humor  may 
escape  gradually  ;  any  rush  of  fluid  is  likely  to  carry  the 
iris  into  the  wound  and  cause  a  permanent  prolapse,  a 
result  to  be  carefully  avoided.  If  prolapse  occur  the  iris 
should  be  excised,  and  the  operation  then  becomes  a  very 
peripheral  iridectomy.  A  moderate  degree  of  bulging  and 
separation  of  the  lips  of  the  two  scleral  wounds  takes  place 
for  a  week  or  two,  when  the  scar  flattens  down  and  finally 

*  De  Wecker  makes  it  1  mm.  from  the  clear  coroea.     In   my  own 
operations  the  distance  is  generally  about  2  mm. 


OPERATIONS     FOR    CATARACT.  415 

a  mere  bluish  line  is  left.  Sclerotomy  is  also  performed 
with  a  triangular  keratome,  Fig.  149,  the  incision  being 
just  as  for  a  very  peripheral  iridectomy,  but  no  iris  being 

Fig.  152. 


Diagrammatic  section  of  ciliary  region,  showing  path  of  wound  in 

iridectomy  for  glaucoma  (7)  and  in  sclerotomy   (S). 

(Compare  Fig.  100,  1  and  2.) 

removed  or  allowed  to  prolapse.  Sclerotomy  is  difficult  to 
perform  well,  is  not  free  from  risk,  and  on  the  whole  has 
not  answered  early  expectations  ;  it  is,  however,  valuable 
as  a  reserve  for  certain  cases.  In  Fig.  152,  /  shows  the 
line  of  incision  in  iridectomy  for  glaucoma,  and  S  the  line 
in  sclerotomy;  comparison  with  Fig.  100,  however,  will 
show  that  even  in  iridectomies  for  glaucoma  the  position 
of  the  wound  may  vary  a  good  deal. 

G.  Operations  for  Cataract. 

1.  Extraction  of  cataract  has  been  systematically  prac- 
tised for  nearly  a  century  and  a  half.  The  operation  has 
passed  through  several  important  changes,  and  procedures 
differing  more  or  less  from  each  other  are  still  in  use.  All 
the  operations  are  difficult  to  perform  well,  and  much 
practice  is  needed  to  insure  the  best  prospect  of  success. 
The  sources  of  possible  failure  are  many,  and  as  in  avoiding 
one  we  are  apt  to  fall  into  another,  it  cannot  be  expected 
that  any  one  operation  will,  in  all  its  details,  ever  be  uni- 


416 


OPERATIONS. 


versally  adopted.  At  present  the  majority  of  surgeons 
adhere  more  or  less  closely  to  the  operation  known  as  the 
"modified  linear"  method  of  von  Graefe,  in 
which  iridectomy  forms  a  step  in  the  pro- 
ceeding. There  is,  however,  a  strong  ten- 
dency, especially  amongst  operators  of  large 
experience,  to  dispense  with  iridectomy  on 
account  of  the  cosmetic  and  optical  advan- 
tages of  a  round  pupil.  For  the  last  twelve 
months  I  have  operated,  as  a  rule,  without  iri- 

:  Fig.  153. 


^ 


Graefe's  cataract  kuife. 


Fig.  loi. 


Cataract  spoon. 


]  dectomy.  That  many  cataracts  can  be  easily 
I  and  safely  extracted  without  iridectomy  admits 
^  of  no  doubt ;  and  it  appears  equally  certain 
:  that  some  cases,  especially  where  the  lens  is 
I  very  hard,  cannot  be  dealt  with  properly  in 
^  this  way.  Any  operator  of  experience  is  fully 
justified  in  leaving  the  iris  intact  unless  there 
be  difficulty  in  delivering  the  lens  through  the 
pupil,  or  difficulty  in  perfectly  replacing  the 
iris  afterward,  or  the  patient  be  very  restless  ; 
in  either  of  these  events  iridectomy  should  be 
performed  at  the  moment  when  required. 
Eserine  used  just  before  and  a  few^  times  after 
the  operation  appears  to  assist  in  preventing 
prolapse  of  the  iris  afterward.  If  prolapse 
occurs,  as  it  may,  several  days  after  operation,  it  is  best  to 
remove  it  carefully  as  in  a  case  of  accidental  wound. 


OPERATIONH  FOR  CATARACT.        417 

All  operations  for  extraction  of  hard  cataract  agree  in 
the  following  points:  (1)  An  incision  is  made  in  the  cornea, 
at  the  junction  of  the  cornea  and  sclerotic,  or  even  slightly 
in  the  sclerotic,  large  enough  to  give  exit  to  the  crystalline 
lens  unbroken  and  unaltered  in  shape.  The  knife  now  almost 
universally  employed  is  the  narrow,  thin,  straight  knife  of 
von  Graefe,  Fig.  153.  (2)  The  capsule  is  freely  opened 
with  a  small,  sharp-pointed  instrument,  cystitome  or 
pricker.  Fig.  155.  (3)  The  lens  is  removed  through  the 
rent  in  the  capsule  (the  latter  structure  remaining  behind), 
either  by  pressure  and  manipulation  outside  the  eye,  or  by 
means  of  a  traction  instrument,  scoop  or  spoon,  Fig.  154, 
passed  into  the  eye  just  behind  the  lens.  Few  operators, 
however,  use  the  scoop,  except  for  certain  emergencies  and 
special  cases.  (4)  Iridectomy  is  very  often  performed  as 
the  second  stage.  This  part  of  the  operation  was  originally 
introduced  less  with  the  object  of  facilitating  the  exit  of  the 
lens,  than  of  preventing  prolapse  of  the  iris  and  lessening 
the  after-risks  of  iritis.  But  these  untoward  results  do  not 
occur  so  often,  with  cocaine  and  antiseptics,  as  formerly; 
and,  as  already  stated,  many  now  omit  iridectomy.  A 
few  of  the  many  surgeons  who  adhere  to  iridectomy  prefer 
to  perform  it  some  weeks  or  months  before  the  extraction 
of  the  lens,  iireliminary  iridectomy ;  the  theory  being 
that  iritis  is  less  likely  to  follow  if  the  cut  edges  of  the  iris 
are  soundly  healed  before  the  lens  rubs  against  them  on  its 
way  out.  Patients,  however,  will  not,  or  cannot,  always 
submit  to  this  subdivision  of  the  operation  for  cataract,  and 
for  this  and  other  reasons  of  expediency  preliminary  iridec- 
tomy cannot  be  employed  so  largely  as  may,  perhaps,  on 
theoretical  grounds,  be  desirable.  In  my  own  practice  I 
keep  it  for  cases  where  special  risks  or  difficulties  are 
present,  as,  e.  g.,  where  the  patient  has  only  one  eye. 

The  following  are  the  chief  varieties  of  operation  for 
cataract  at  present  practised : — 

18* 


418  OPERATIONS. 

(a)  Simple  linear  extraction,  best  described  here,  though 
not  applicable  to  hard  cataract.  A  small  incision  (4  to  6 
mm.)  is  made  by  a  keratome,  Fig.  149,  well  within  the 
margin  of  the  cornea,  with  a  small  iridectomy,  if  necessary. 
After  opening  the  capsule  the  lens  is  squeezed  out  piece- 
meal, or  coaxed  out  b}^  depressing  the  outer  lip  of  the 
wound  with  the  curette,  Fig.  155.  Only  quite  soft  cata- 
racts, or  those  in^which  the  nucleus,  though  firm,  is  very 
small,  can  be  so  dealt  with. 

The  wish  to  extend  the  principle  of  a  straight  wound  to 
full-sized  hard  cataracts,  led  von  Graefe,  in  1865,  to  intro- 
duce i^b)  the  modified  linear  or  peripheral  linear  extrac- 
tion, in  which  the  incision  lies  slightly  beyond  the  sclero- 
corneal  junction,  Fig.  157,  2,  and  consequently  involves  the 
conjunctiva,  of  which  a  flap  is  made.  The  incision  is  in- 
tended to  form  an  arc  of  the  largest  possible  circle,  i.  e. ,  of  the 
scleral,  not  of  the  corneal,  curve ;  its  plane,  therefore,  must 
lie  as  nearly  as  may  be  in  a  radius  of  the  scleral  curve,  and 
at  a  considerable  angle  with  that  of  the  iris,  Fig.  158,  2. 
A  large  iridectomy  is  performed  as  the  second  stage.  The 
incision  is  made  with  the  Graefe  knife,  Fig.  153,  which  is 
at  first  directed  toward  the  centre  of  the  pupil  and  then 
brought  up  to  the  seat  of  counter-puncture.  The  edge  is 
turned  somewhat  forward  during  the  greater  part  of  the 
proceeding,  and  the  cut  completed  by  sawing  movements, 
if  needful.  The  disadvantages  of  the  peripheral  linear 
extraction  are :  the  frequency  of  bleeding  from  the  con- 
junctiva into  the  anterior  chamber,  the  parts  being  thus 
obscured  ;  a  considerable  risk  of  loss  of  vitreous,  owing  to 
the  peripheral  position  of  the  wound  and  sometimes  a  dif- 
ficulty in  making  the  lens  present  well ;  a  small  but  appre- 
ciable risk  that  the  operated  ej^e  will  set  up  sympathetic 
inflammation,  the  wound  lying  in  the  "  dangerous  region ;" 
lastly,  there  is  a  tendency  to  make  the  wound  rather  too 
short  in  order  to  avoid  some  of  these  risks,  and  thus  diffi- 


OPERATIONS  FOR  CATARACT.        419 

culties  are  introdaced  in  the  clean  removal  of  the  lens. 
Its  great  advantan^e  lies  in  the  very  small  attendant  risk 
of  suppurative  inflammation. 

A  variety  of  this  operation  consists  in  placing  the  in- 
cision rather  further  down,  and  at  the  same  time  giving  it 
a  somewhat  sharper  curve,  so  that  it  forms  an  arc  of  a 
smaller  circle  than  before,  but  is  still  not  concentric  with 
the  cornea,  Fig.  157,  3,  upper  section.  The  puncture  is 
directed  somewhat  downward  (as  at  the  right-hand  end  of 
the  figure),  and  its  plane,  which  at  the  puncture  and 
counter-puncture  is  almost  parallel  with  the  iris,  alters  to 
nearly  a  right  angle  at  the  summit  of  the  flap.  The  track 
of  the  wound,  if  shaded,  would  appear  as  in  the  figure. 

(c)  Short  flap  (De  Wecker). — The  incision,  made  with 
the  same  knife,  lies  exactly  at  the  sclero-corneal  junction, 
and  is  of  such  an  extent  that  it  has  a  height  of  about  3  mm. 
(^  of  the  diameter  of  the   cornea),  Fig.   156.     A   narrow 

Fig.  156, 


Short  flap. 

rim  of  conjunctiva  remains  attached  to  the  flap.  The 
iridectomy,  if  made,  is  small,  as  in  Fig.  148.  For  very 
bulky  cataracts  this  incision  is  not  quite  large  enough. 

{d)  The  incision  has  nearly  the  same  curve  and  plane  as 
in  h,  but  the  greater  part  of  it  lies  considerably  within  the 
margin  of  the  cornea,  corneal  section,  and  iridectomy  is 
usually  dispensed  with.  Liebreich  and  Bader  made  the 
section  downward,  its  plane  forming  an  angle  of  about  45° 
with  that  of  the  iris,  Fig,  158,  3,  lower  section.  In 
Ijebrun's  corneal  operation  an  almost  identical  section  is 


420 


OPERATIONS 


made  upward  ;  the  upper  section  of  3,  Fig.  157,  if  placed 
further  in  the  cornea,  would  nearly  represent  it.  The  cor- 
neal operations,  without  iridectomy,  are  easy  to  perform, 


Fig.  157. 


I  2.  3 

Paths  of  iucisiou  for  extractioi  of  cataract.  1 ,  old  flap  ;  2,  peripheral 
linear  ;  3  (upper  Fig.),  a  variety  of  the  peripheral  linear  ;  (lower Fig.) 
corneal  section.  The  wound  appears  as  a  narrow  slit  (2)  or  a  broad 
tract  (1),  when  seen  from  the  front,  according  to  the  inclination  of  its 
plane.  The  doited  circle  shows  the  average  outline  of  the  lens. 
Compare  Fig,  158. 

compared  with  those  in  which  the  section  lies  further  back  ; 

the  wound,  however,  does  not,  on  the  whole,  heal  so  quickly, 
and  is  more  likely  to  reopen  about 
the  fourth  or  fifth  day. 

(e)  Old  flap  extraction  (Daviel, 
Beer,  now  very  little  used). — The 
incision  was  slightly  within  the  visi- 
ble margin  of  the  cornea,  concentric 
with  it,  and  equal  to  at  least  half 
its  circumference,  1,  Fiij.  157,  thus 


Fjg  158. 


The  same  sections  seen 
in  profile,  showing  the 
plane  of  the  incision  in 
1,  2,  and  the  lower  sec- 
tion of  3. 


Fig.  159. 


Beer's  cataract  knife. 


forming  a  large  arc  of  a  small  circle  ;  the  plane  of  the  in- 
cision being  parallel  with  that  of  the  iris,  1,  Fig.  158  ;  no 
iridectomy  was  made.  The  incision  was  made  with  the 
triangular  knife  of  Beer,  Fig.  159,  in  which  the  blade  near 
its  heel  is  somewhat  wider  than  the  height  of  the  flap,  the 


OPERATIONS  FOR  CATARACT.        421 

section  being  completed  by  simply  pushing  the  knife  across 
the  anterior  chamber  flat  with  the  iris,  its  back  correspond- 
ing to  the  base  of  the  intended  flap.  The  inner  length  of 
the  wound  is  less  than  the  outer  by  the  thickness  of  the 
obliquely  cut  cornea  at  each  end,  1,  Fig  157. 

The  flap  operation  was  usually  done  without  either 
anaesthesia,  speculum,  or  fixation  forceps.  The  after-treat- 
ment was  troublesome.  But  the  great  height  of  the  flap, 
in  proportion  to  its  width,  renders  it  very  liable  to  gape  or 
even  to  fall  forward,  and  this,  with  the  fact  that  the  whole 
wound  lies  in  corneal  tissue,  considerably  increases  the  risks 
of  large  and  dangerous  prolapse  of  the  iris  and  of  rapid 
suppurative  inflammation  of  the  cornea.  For  these  reasons 
the  old  flap  extraction  has  been  almost  abandoned  in  favor 
of  the  peripheral  linear,  corneal  section,  and  short  flap 
operations,  which  yield  a  much  larger  average  of  useful 
eyes. 

Historically,  the  flap  operation  was  the  earliest ;  then 
came  the  linear  operation  ;  thirdly,  the  modified  or  peri- 
pheral linear  operation,  with  iridectomy  ;  then  the  modern 
corneal  operations  and  short  flap,  the  aim  of  which  is  to 
gain  the  substantial  advantages  both  of  the  old  flap  and 
the  modified  linear  methods,  without  the  great  risks  of  the 
former  or  the  imperfections  of  the  latter;  lastly,  iridectomy 
has,  as  stated  above,  been  again  abandoned,  more  or  less 
completely,  by  many  operators. 

Of  other  operations  the  most  important  is  Pagenstecher's, 
in  which  the  lens  is  removed  by  a  scoop  in  its  unbroken 
capsule.  It  is  most  applicable  to  cataracts  which  are 
over-ripe  or  are  complicated  with  old  iritis,  and  to  Mor- 
gagnian cataract. 

(For  methods  of  dealing  with  unripe  senile  cataract  see 
p.  202.) 

The  chief  complications  \\h'ich  may  arise  during  extrac- 
tion of  cataract  are:  (1)  too  short  an  incision  ;  this  is  best 


422  OPERATIONS. 

remedied  by  enlarging  with  a  small  bent  "  secondary- 
knife. "  (2)  Escape  of  vitreous  before  expulsion  of  the 
lens ;  this  is  a  signal  for  the  prompt  removal  of  the  lens 
with  a  scoop,  Fig.  154,  the  vitreous  being  afterwards  cut 
oflf  level  with  the  wound  by  scissors.  (3)  Portions  of  the 
lens  remaining  behind  after  the  chief  bulk  has  been  ex- 
pelled ;  they  should  be  coaxed  out  by  gentle  manipulation 
after  removal  of  the  speculum. 

After-treatment  of  Extraction. — The  patient  is 
best  in  bed  for  from  four  to  seven  days.  The  dressing  con- 
sists of  a  piece  of  soft  linen  overlaid  by  a  pad  of  cotton- 
wool or  alembroth  tissue,  and  kept  in  place  by  a  four-tailed 
bandage  of  knitted  cotton,  or  narrow  flannel  or  open 
tissue  roller.  Both  eyes  are  to  be  bandaged.  The  room 
is  usually  kept  partly  dark  for  about  a  week,  all  dressings 
and  examinations  being  made  by  the  light  of  a  candle. 

Some  operators  keep  their  cataract  patient  from  the  first  in 
daylight,  and  with  no  other  dressing  than  some  strips  of  isin- 
glass plaster  to  maintain  closure  of  the  lids.  Others  bandage 
only  the  operated  eye.  Old  people  occasionally  get  delirious 
if  kept  in  bed  and  in  the  dark  after  extraction  of  cataract  or 
iridectomy,  and  for  such,  at  any  rate,  the  ordinar}'  rules  as  to 
bandaging,  darkness,  and  confinement  to  bed  must  be  relaxed. 
In  my  experience  the  subjects  of  this  delirium  have  usually 
been  alcoholics;  but  I  believe  that  imprudent  use  of  strong 
mydriatics  may  produce  it  in  some  old  persons  who  have  not 
been  habitual  drinkers. 

During  the  first  few  hours  there  will  be  some  soreness 
and  smarting,  and  at  the  first  dressing,  from  twelve  to 
twenty-four  hours  after  operation,  a  little  blood-stained 
fluid,  but  after  this  there  should  be  no  material  discomfort, 
and  nothing  more  than  a  little  mucous  discharge,  such  as  old 
people  often  have.  The  dressings  are  removed,  and  the  lids 
gently  cleansed  with  warm  water  once  or  twice  a  day,  their 
edges  being  separated  by  gently  drawing  down  the  lower 


OPERATIONS  FOR  CATARACT.        423 

lid,  so  as  to  allow  any  retained  tears  to  escape  ;  this  cleans- 
ing is  very  grateful  to  the  patient.  Some  surgeons  open 
the  lids  and  look  at  the  eye  the  day  after  the  operation  ; 
but  many  prefer  to  leave  them  closed  for  several  days 
unless  there  are  signs  that  the  case  is  doing  badly.  It  is  a 
good  practice  to  use  one  drop  of  atropine  daily  after  the 
third  day,  to  prevent  adhesions  should  iritis  set  in  ;  but  if 
no  iridectomy  have  been  made,  I  prefer  not  to  use  atropine 
till  about  the  fifth  day,  because  if  the  wound  should  reopen 
whilst  the  pupil  is  dilated  prolapse  of  iris  is  more  likely  to 
occur  than  if  the  pupil  be  small.  When  first  examined 
from  two  to  seven  days  after  operation,  the  eye  is  always 
rather  congested  from  having  been  tied  up;  but  there 
should  be  no  chemosis,  the  wound  should  be  united  so  as 
to  retain  the  aqueous,  and  its  edges  clear.  The  pupil  is 
expected  to  be  black,  unless  it  is  known  that  portions  of 
lens  matter  have  been  left  behind.  If  all  be  well,  the 
bandage  may  be  left  ofi"  during  the  daytime  at  the  end  of 
a  week  or  ten  days,  a  shade  being  worn  ;  but  it  should  be 
reapplied  at  night  for  the  first  two  or  three  weeks  to  pre- 
vent accidents  from  movements  during  sleep.  At  the  end 
of  a  fortnight,  if  the  weather  be  fine,  the  patient  may 
begin  to  go  out,  the  eyes  being  carefully  protected  from 
light  and  wind  by  dark  goggles,  and  he  may  be  out  of  the 
surgeon's  hands  in  from  three  to  four  weeks. 

After-operatioxs — When  iritis  occurs  the  pupil  be- 
comes more  or  less  occluded  by  false  membrane,  and  the 
subsequent  contraction  of  this  membrane  may  draw^  the  iris 
toward  the  scar,  so  that  the  pupil  is  at  once  blocked  and 
displaced.  Fig.  160.  In  slight  cases,  where  the  pupil  is  not 
dragged  out  of  place,  sight  is  greatly  improved  by  simply 
tearing  across  the  membrane  and  capsule  with  a  fine  needle, 
and  treating  the  case  as  after  discission  of  soft  cataract. 
In  doing  this  the  needle  should  be  passed  deeply  enough  to 
tear  the  posterior  capsule  also,  so  that  the  vitreous  by  bulg- 


424 


OPERATIONS 


ing  forward  may  keep  the  opening  in  the  capsule  patent 
(compare  Discission  of  Soft  Cataract),  in  which  care  is 
taken  not  to  go  so  deeply.  But  in  severer  cases  an  artificial 
pupil  must  be  made,  either  by  iridectomy  or  iridotomy. 


Fig.  \m. 


Diagram  of  occlusion  and  displacement  of  pupil  from    iritis,  after 
upward  extraction  of  cataract. 

2.  Solution  (Discission)  operations — In  these  the  lens 
is  gradually  absorbed  by  the  action  of  the  aqueous  humor 
admitted  through  a  wound  in.  the  capsule.  (1)  The  pupil 
is  fully  dilated  by  atropine ;  (2)  the  lids  are  held  open  by 
the  fingers,  or  a  stop  speculum  and  fixation  forceps  used  ; 
(3)  a  fine  cataract  needle,  Fig.  162,  is  directed  to  a  point 
a  little  within  the  border  of  the  cornea  (usually  the  outer 
border),  and  when  close  to  its  surface  is  plunged  quickly 
and  rather  obliquely  into  the  anterior  chamber.     Its  point 


Fig.  161. 


Fig.  162. 


Cataract  needle. 


Discission  of  cataract. 


is  then  carried  to  the  centre  of  the  pupil.  Fig.  162,  dipped 
back  through  the  lens-capsule,  and  a  few  gentle  movements 
made  so  as  to  break  up  the  centre  of  the  anterior  layers 
of  the  lens;  (4)  the  needle  is  then  steadily  withdrawn. 
Special  care  is  taken  not  to  wound,  nor  even  touch,  the  iris, 


OPERATIONS  FOR  CATARACT.        425 

either  on  entering  or  withdrawing  the  needle,  not  to  stir 
up  the  lens  too  freely,  nor  to  go  so  deeply  as  to  perforate 
the  posterior  capsule  and  so  engage  the  vitreous.  A  general 
anassthetic  is  necessary  only  for  young  children  or  exces- 
sively nervous  patients ;  but  it  should  always  be  in  readi- 
ness, and  the  patient  prepared. 

After-treatment. — The  pupil  is  kept  widely  dilated 
with  atropine  (F.  31),  a  drop  being  applied  after  the  opera- 
tion, and  at  least  six  times  a  day  afterward,  or  much  oftener 
if  there  be  threatening  of  iritis.  Ice  or  iced  water  is  usually 
to  be  applied  constantly  for  twenty-four  to  forty-eight  hours 
after  the  operation,'  as  for  threatened  traumatic  iritis  (p. 
160),  and  the  patient  to  remain  in  bed  in  a  darkened  room 
for  a  few  days.  A  little  ciliary  congestion  for  two  or  three 
days  need  cause  no  uneasiness,  but  the  occurrence  of  pain, 
increase  of  congestion,  and  alteration  in  the  color  of  the 
iris  (commencing  iritis)  are  indications  for  the  application 
of  leeches  near  the  eye,  and  the  more  frequent  use  of  atro- 
pine. 

If  the  cataract  was  complete,  no  marked  change  will  be 
seen  for  some  wrecks;  if  partial  {e.  g.,  lamellar),  in  a  day 
or  two  the  part  of  the  lens  near  the  needle  wound,  and  in 
a  few  days  the  whole  lens,  will  become  opaque.  In  from 
sixtoeight  weeks  the  lens  will  have  become  notably  smaller, 
flattened,  or  hollowed  on  the  front  surface.  If  the  eye  be 
perfectly  quiet,  but  not  unless,  the  operation  may  now  be 
repeated  in  exactly  the  same  way,  and  with  the  same  after- 
treatment  and  precautions,  but  the  needle  may  be  used 
more  freely.  The  bulk  of  the  lens  will  generally  disap- 
pear after  the  second  operation,  but  the  needle  may  have  to 
be  used  a  third  or  a  fourth  time  for  the  disintegration  of 
small  residual  pieces,  or  in  order  to  tear  the  capsule  if  it 

1  I  have  to  thank  my  colleague,  Mr.  Gunn,  for  this  valuable  sugges- 
tion. 


426  OPERATIONS. 

have  not  retracted  enough  to  leave  a  clear  central  pupil.  A 
small  whitish  dot  remains  in  the  cornea  at  the  seat  of  each 
needle  puncture. 

3.  Extraction  by  suction. — This  operation,  like  simple 
linear  extraction,  is  applicable  to  completely  soft  cataracts. 
The  pupil  is  to  be  dilated  by  atropine.  The  lens-capsule  is 
opened  as  in  discission,  but  more  freely.  Then  an  incision 
is  made  obliquel}^  through  the  cornea,  between  its  centre 
and  margin,  with  a  keratome,  Fig.  149,  or  broad  needle, 
Fig.  144,  and  the  nose  of  the  syringe  passed  through  the 
wound  and  gently  dipped  into  the  lacerated  lens-substance. 
By  very  gentle  suction  the  semi-fluid  lens-matter  is  then 
drawn  gradually  into  the  syringe.  The  instrument  is  not 
to  be  passed  behind  the  iris  in  search  of  fragments.  Nearly 
the  whole  of  the  lens  can  thus  be  removed.  The  after- 
treatment  is  the  same  as  for  needle  operations.  Two  forms 
of  syringe  are  in  use :  Teale's,  in  which  the  suction  is  made 
by  the  mouth  applied  to  a  piece  of  flexible  India-rubber 
tubing;  Bowman's,  in  which  the  suction  is  obtained  by  a 
sliding  piston  worked  by  the  thumb  moving  along  the 
syringe.  It  is  often  better,  and  in  lamellar  cataract  neces- 
sary, to  break  up  the  lens  freely  with  a  fine  needle  a  few 
days  before  using  the  syringe,  and  thus  allow  it  to  be 
thoroughly  macerated  and  softened  in  the  aqueous  humor; 
atropine  and  ice  must  be  used  freely  in  the  interval  between 
this  needle  operation  and  the  suction  ;  and  the  surgeon 
must  be  prepared  to  interfere  before  the  day  appointed  for 
the  suction,  should  severe  pain  or  increase  of  tension  occur 
from  the  rapid  swelling  of  the  lens  (p.  20T).  Suction  is 
more  difficult  to  perform,  and  perhaps  less  safe,  than  simple 
linear  extraction,  but  I  have  myself  no  objection  to  make 
against  it. 

Anaesthesia  in  Ophthalmic  Surgery — Before  the  intro- 
duction of  cocaine  (October,  1884)  there  was  much  diversity 
of  practice  in  respect  to  anaesthesia,  many  surgeons  pre- 


OPERATIONS  FOR  CATARACT.        42T 

ferring  to  perform  extraction  of  cataract,  tenotomy  for 
squint,  and  simple  iridectomy,  without  anaesthesia,  whilst 
others  preferred  ether  or  chloroform  for  nearly  all  opera- 
tions. Cocaine  has  immensely  facilitated  operating  without 
general  anaesthesia,  but  of  course  some  will  continue  to  use 
ether  or  chloroform,  where  others  feel  able  to  rely  solely  on 
the  local  anaesthetic.  In  usingcocaineforthe  eye  we  haveto 
remember  that  it  does  not  affect  the  sensibility  of  the  borders 
of  the  lids,  nor  in  any  constant  manner  that  of  the  iris, 
unless  used  many  times  for  at  least  half  an  hour,  nor  that 
of  the  muscles  and  deeper  parts,  unless  injected  under  the 
conjunctiva.  Hence  the  introduction  and  pressure  of  the 
speculum  are  always  more  or  less  felt,  there  is  usually  some 
little  pain  when  the  iris  is  seized  and  drawn  out,  and  de- 
cided pain  when,  in  tenotomy,  the  tendon  is  stretched  on 
the  hook,  unless  subconjunctival  injection  ha  ve  been  resorted 
to.  It  must  further  be  remembered  that  the  patient  is  con- 
scious and  knows  that  something  critical  is  being  done,  and 
that  his  good  behavior  depends  almost  as  much  on  absence 
of  fear  as  on  absence  of  feeling;  and,  again,  that  the  pain- 
lessness of  one  step  of  an  operation,  e.  g.,  the  section  in 
extraction  of  cataract,  contrasts  strongly  with  the  sensa- 
tion of  pain  felt  in  another  stage,  e.  g.,  the  iridectomy,  and 
that  the  patient  will  be  likely  to  start  or  jump,  unless 
warned,  at  such  a  stage.  My  own  experience  leads  me  to 
use  cocaine  in  all  cataract  extractions  and  discissions,  unless 
for  some  peculiar  reason  ether  or  chloroform  be  needed,  for 
nearly  all  tenotomies  and  operations  for  corneal  ulcer  and 
conical  cornea,  and  for  some  simple  iridectomies ;  and  to 
avoid  it  usually  in  iridectomy  for  glaucoma  and  for  synechia 
whether  anterior  or  posterior.  I  have  not  myself  used  it 
much  for  lachrymal  cases  ;  nor  have  I  excised  the  eyeball 
under  its  influence ;  but  it  may  be  used  for  both  purposes 
with  fair  success.  For  small  lid  tumors,  subcutaneous 
injection  is  very  successful.     For  granular  lids  or  lupus  of 


428  OPERATIONS. 

conjunctiva,  a  strong  solution,  10  to  20  per  cent.,  may  be 
painted  on  before  touching  with  actual  cautery  or  caustics; 
but  it  is  better  for  such  cases,  and  also  whenever  the  eye- 
ball is  congested  and  painful,  to  use  the  solid  cocaine  salt, 
powdered  and  rubbed  over  the  surface  with  a  brush  or  the 
finger.  For  cataract,  a  solution  of  2  per  cent.,  or  a  single 
disc  containing  ^Iq  grain,  repeated  three  times  within  five 
minutes  of  the  operation,  is  generally  quite  enough.  Solu- 
tions should  be  freshly  made. 


PART  III. 


DISEASES  OF  THE  EYE  IN  RELATION  TO 
GENERAL  DISEASES. 


CHAPTER    XXIII. 

In  stating  very  shortly  the  most  important  facts  bearing 
on  the  connection  between  diseases  of  the  eye  and  of  other 
parts  of  the  body,  it  is  convenient  to  make  the  following 
subdivisions  :  (A)  the  eye-changes  occur  as  part  of  a  gen- 
eral disease  ;  (B)  the  ocular  disease  is  symptomatic  of  some 
local  malady  at  a  distance ;  (C)  the  eye  shares  in  a  local 
process,  affecting  the  neighboring  parts. 

(For  the  clinical  details  of  the  various  eye  diseases  re- 
ferred to  in  this  chapter,  see  Part  11.) 

A.  General  diseases,  in  which  the  eye  is  liable  to  suffer. 

Syphilis  is,  directly  or  indirectly,  the  cause  of  a  large 
proportion  of  the  more  serious  diseases  of  the  eye. 

1.  Acquired  syphilis. — Primary  stage :  Hard  chancres 
are  occasionally  seen  on  the  eyelid,  and  even  far  back  on 
the  conjunctiva. 

Secondary  stage :  Sore-throat,  shedding  of  hair,  eruption, 
and  condylomata.  IritW\?>  common  between  two  and  eight 
or  nine  months,  and  does  not  occur  later  than  about  eigh- 
teen months,  after  the  contagion ;  in  from  two-thirds  to 
three-fourths  of  the  cases  both  eyes  suffer;  there  is  a  marked 
tendency  to  exudation  of  lymph,  plastic  iritis,  shown  by 
keratitis  punctata,  haze  of  cornea,  and  less  commonly  by 


430  ETIOLOGY. 

lymph-noduIes  on  the  iris.  In  some  cases  there  are  symp- 
toms of  severe  cyclitis,  leading  to  detachment  of  retina  and 
secondary  cataract,  and  but  little  iritis  ;  but  the  cyclitis  of 
acquired  syphilis  does  not  give  rise  to  ciliary  staphyloma. 
Syphilitic  iritis,  though  sometimes  protracted,  rarely  re- 
lapses after  complete  subsidence.  Choroiditis  and  retinitis 
generally  set  in  rather  later,  from  six  months  to  about  two 
years  after  the  chancre  ;  seldom  as  late  as  four  years.^  The 
two  conditions  are  most  often  seen  together,  but  either  may 
occur  singly ;  and  in  each  the  vitreous  generally  becomes 
inflamed.  These  conditions  are  essentially  chronic,  the 
retinitis  being  often,  and  the  choroiditis  sometimes,  liable 
to  repeated  exacerbations  or  recurrences  ;  whilst  in  some 
cases  the  secondary  atrophic  changes  progress  slowly  for 
years,  almost  to  blindness,  often  with  pigmentation  of  the 
retina.  Syphilitic  choroiditis  and  retinitis  usually  affect 
both  eyes, but  often  in  an  unequal  degree,  and  even  when 
severe  the  disease  is  occasionally  limited  to  one  eye.  Kera- 
titis, indistinguishable  from  that  of  inherited  syphilis,  is 
amongst  the  rarest  events  in  the  acquired  disease  ;  when  it 
occurs  it  is  usually  in  the  secondary  stage  of  the  disease. 

Later  periods  :  Ulceration  of  the  skin  and  conjunctiva 
of  the  lids,  gummatous  infiltration  of  the  lids  and  sclerotic, 
and  nodes  in  the  orbit,  whether  cellular  or  periosteal,  occur 
but  rarely.  Oculo-motor  paralysis  is  one  of  the  frequent 
ocular  results  of  syphilis.  It  may  depend  upon  gumma, 
syphilitic  neuroma,  of  the  affected  nerve  or  nerves  in  the 
orbit  or  in  the  skull,  or  upon  gummatous  inflammation  of 
the  dura  mater  at  the  base  of  the  skull,  matting  the  nerves 
together,  or  on  disease  of  nerve-centres.  The  gummatous 
nerve-lesions  seldom  occur  very  late  in  tertiary  syphilis. 

The  optic  disc  is  often  inflamed  or  atrophied  as  an  indi- 

1  A  few  cases  are  on  record  in  which  it  appeared  not  to  have  begun 
till  about  ten  years  after  infection. 


ETIOLOGY.  431 

rect  result  of  syphilitic  disease  of  the  eye  or  of  the  nervous 
system ;  but  the  terms  "  syphilitic  optic  neuritis"  or 
"syphilitic  optic  atrophy"  are  not  often  applicable  in  any 
more  direct  sense.  The  retinitis  of  the  secondary  stage 
affects  the  disc,  and,  when  atrophy  of  the  retina  and  chor- 
oid occurs,  the  disc  becomes  wasted  in  proportion  ;  w^hilst 
in  rare  cases  the  retinitis  of  secondary  syphilis  is  replaced 
by  w^ell-marked  papillitis.  Such  cases  must  not  be  confused 
with  others,  still  more  rare,  in  which  double  papillitis,  pass- 
ing into  atrophy,  occurs  with  all  the  symptoms  of  severe 
meningitis,  in  secondary  syphilis.  Tertiary  syphilitic  dis- 
ease, anywhere  within  the  cranium,  commonly  causes  optic 
neuritis,  in  the  same  way  as  do  other  coarse  intracranial 
lesions;  but  neuritis  may  also  be  caused  more  directly  by 
gummatous  inflammation  of  the  trunk  of  the  optic  nerve, 
cr  of  the  chiasma.  Primary  progressive  atrophy  of  the 
discs  occurs  in  association  with  locomotor  ataxy  and  oph- 
thalmoplegia externa  of  syphilitic  origin ;  probably  in  a 
few  instances  the  optic  atrophy  occurs  alone,  or  for  a  time 
precedes  the  other  changes  in  syphilitic,  as  it  is  known  to 
do  in  non-syphilitic,  ataxy. 

Sight  is  liable  to  be  rapidly  damaged  from  severe  acute 
loss  of  blood,  especially  from  the  stomach ;  usually  both 
eyes  suffer,  but  often  unequally.  When  seen  quite  early 
papillitis  has  been  found,  but  the  cases  are  often  not  seen 
till  the  appearances  of  atrophy  have  come  on. 

2.  Inherited  syphilis. — In  the  secondary  stage :  Iritis 
corresponding  to  that  in  the  acquired  disease  is  seen  in  a 
small  number  of  cases,  and  occurs  between  the  ages  of 
about  two  and  fifteen  months.  "-It  often  gives  rise  to  much 
exudation,  leading  to  occlusion  of  the  pupil,  and  is  fre- 
quently accompanied  by  deeper  changes,  cyclitis  and  dis- 
ease of  vitreous.  It  is  very  often  symmetrical,  and  is  much 
commoner  in  girls  than  boys.  Choroiditis  and  retinitis,  of 
preciseh'  the  same  forms  as  in  acquired  syphilis,  occur  at 


432  ETIOLOGY. 

the  corresponding-  period  of  the  disease,  i.  e.,  between  six 
months  and  about  three  years  of  age ;  and  they  show  as 
much  (some  observers  think  more)  tendency  to  the  degen- 
erative and  atrophic  results  already  described ;  in  severe 
cases  there  are  not  uncommonly  signs  of  cerebral  degene- 
ration. In  the  later  stages,  keratitis,  which  is  the  com- 
monest eye  disease  caused  by  inherited  syphilis,  occurs.  It 
is  commonest  between  six  and  fifteen  years  old,  but  is  some- 
times seen  as  early  as  two  or  three  years,  and  is  occasionally 
deferred  till  after  thirty.  The  disease  is  frequently  com- 
plicated with  iritis  and  cyclitis,  and,  though  tending  to 
recovery,  shows  a  considerable  liability  to  relapse.  It 
almost  always  attacks  both  eyes,  though  sometimes  at  an 
interval  of  many  months.  When  the  patient  is  unusually 
young,  the  disease  as  a  rule  runs  a  mild  and  short  course. 
The  oculo-motor  palsies  occur  but  rarely  in  inherited 
syphilis,  but  a  few  well-authenticated  cases  are  on  record. 

Smallpox  causes  inflammation  and  ulceration  of  the 
cornea,  leading,  in  the  worst  cases,  to  its  total  destruction, 
but  in  a  large  number  to  nothing  worse  than  a  chronic 
vascular  ulcer.  The  corneal  disease  comes  on  some  days 
after  the  eruption  (tenth  to  fourteenth  day  from  its  com- 
mencement), and  after  the  onset  of  the  secondary  fever. 
Iritis,  uncomplicated  and  showing  nothing  characteristic 
of  its  cause,  sometimes  occurs  some  weeks  after  an  attack 
of  smallpox.  Only  in  very  rare  cases  do  variolous  pustules 
form  on  the  eye,  and  even  then  they  are  alw^ays  on  the 
conjunctiva,  not  on  the  cornea. 

Scarlet  fever,  typhus,  and  some  other  exanthemata  may 
be  followed  by  rapid  and  complete  loss  of  sight,  lasting  a 
day  or  tw^o,  showing  no  ophthalmoscopic  changes,  and  end- 
ing in  recovery.  Such  attacks  are  believed  to  be  uraemic, 
or  at  any  rate  dependent  on  some  toxic  condition  of  the 
blood.  A  peculiarity  of  these  cases  is  the  preservation  of 
the  action  of  the  pupils  to  light.     Very  severe  purulent  or 


ETIOLOGY.  433 

diphtheritic   ophthahiiia  sometimes  occurs  during  scarlet 
fever. 

Diphtheria. — By  far  the  commonest  result  is  paralysis, 
often  incomplete,  of  both  the  ciliary  muscles,  cycloplegia ; 
the  pupils  are  not  afTected  except  in  severe  cases,  when 
they  may  be  rather  large  and  sluggish.'  The  symptoms 
generally  come  on  from  four  to  six  weeks  after  the  com- 
mencement of  the  illness,  last  about  a  month,  and  disap- 
pear completely.  Diphtheritic  cycloplegia  is  usually,  but 
not  invariably,  accompanied  by  paralysis  of  the  soft  palate. 
In  most  of  the  cases  seen  by  ophthalmic  surgeons  the  attack 
of  diphtheria  has  been  mild,  sometimes  extremely  so,  the 
case  often  being  described  as  "ulcerated  throat  ;"  but  in- 
quiry often  yields  a  history  of  other  and  severer  cases  in 
the  family,  and  of  general  depression  and  weakness  in  the 
patient  out  of  proportion  to  his  throat  symptoms.  We 
find  that  most  of  the  patients  who  apply  with  diphtheritic 
cycloplegia  are  hypermetropic,  doubtless  because  those  with 
normal,  and,  d  fortiori,  with  myopic,  refraction  are  much 
less  troubled  by  paresis  of  accommodation,  and  often  do 
not  find  it  necessary  to  seek  advice.  Concomitant  conver- 
gent squint  sometimes  develops  in  hypermetropic  children 
during  diphtheritic  paresis,  owing  to  the  increased  efforts 
at  accommodation.  Paralysis  of  the  external  muscles  is 
occasionally  seen ;  I  have  never  myself  seen  any  except 
the  external  rectus  aifected,  and  recovery  has  been  rapid. 

Diphtheritic  and  membranous  ophthalmia  are  occasion- 
ally caused  by  direct  inoculation  of  the  conjunctiva  of  the 
attendant  by  diptheritic  material  from  the  patient's  throat ; 
or  in  the  patient  himself  by  extension  up  the  nasal  duct 
to  the  conjunctiva.  But  in  many  cases  of  "  diphtheritic  " 
and  "membranous"  ophthalmia  the  disease  seems  to  be 
local,  the  inflammation  taking  on  this  special  form  without 

1  Further  observations  are  wanted. 

19 


434  ETIOLOGY. 

ascertainable  relation  to  any  infectious  disease.  No  donbt 
there  is  often  ponietbing'  peculiar  in  the  patient's  health  or 
in  the  state  of  his  eye-tissues  which  <iivcs  a  ])roclivity  to 
this  kind  of  inflammation.  Thus,  diphtheritic  ophthalmia 
of  all  degrees  is  more  common  in  young  children  than  in 
adults;  the  worst  cases  generally  occur  after  measles,  or 
during  or  after  scarlet  fever,  broncho-pneumonia,  or  severe 
infantile  diarrhoea  ;  old  granular  disease  of  the  conjunctiva 
also  confers  a  liability  to  a  diphtheritic  type  of  inflamma- 
tion, and  the  same  tendency  is  sometimes  i^een  in  ophthal- 
mia neonatorum  and  in  gonorrhosal  ophthalmia.  As  there 
seems  but  seldom  any  reason  to  look  upon  diphtheritic 
ophthalmia  as  the  local  manifestation  of  a  specific  blood 
disease,  the  term  "diphtheria  of  the  conjunctiva"  should, 
I  think,  seldom  be  used. 

Measles  is  a  prolific  source  of  ophthalmia  tarsi  in  all  its 
forms,  and  of  corneal  ulcers,  particularlv  of  the  phlyc- 
tenular forms.  It  also  gives  rise  to  a  troui)lesome  muco- 
purulent ophthalmia,  and  under  bad  hygienic  conditions 
this  may  be  aggravated,  by  cultivation  and  transmission, 
into  destructive  disease  of  purulent,  membranous,  or  diph- 
theritic type.  Double  optic  neuritis  has  been  seen  in  sev- 
eral patients  after  measles. 

Mumps. — Dr.  Swan  M.  Burnett^  has  lately  called  atten- 
tion to  haze  of  disc  with  venous  engorgement  of  retina 
and  failure  of  sight  daring  mumps.  (Edema  of  lids  and 
conjunctiva,  and  in  one  case  paresis  of  third  nerve,  point 
to  effusion  in  the  orbit.  The  symptoms,  as  a  rule,  quickly 
subsided. 

Chicken-pox  is  sometimes  followed  by  a  transient  attack 
of  mild  conjunctivitis. 

Whooping-coiigh  often,  like  measles,  leaves  a  proneness 
to  corneal  ulcers.     In  a  lew  rare  cases  the  condition  known 

1  Burnett,  Amer.  Journ.  of  Med.  Sci.,  Jan,  lSS6,p.  86. 


ETIOLOGY.  435 

as  ischaemia  retinae  (sudden,  temporary,  arterial  bloodless- 
ness)  has  occurred. 

Malarial  fevers,  especially  tlie  severe  forms  met  with  in 
hot  countries,  are  sometimes  the  cause  of  retinal  and  other 
intra-ocular  hemorrhages,  and  even  of  considerable  neuro- 
retinitis;  when  there  is  much  pigment  in  the  blood  the 
jBwoUen  disc  may  have  a  peculiar  gray  color.  When  renal 
albuminuria  is  caused  by  malarial  disease,  albuminuric 
retinitis  may  occur.  Simple  optic  neuritis  with  failure  of 
sight,  followed  by  recovery,  seems  to  occur  sometimes,  and 
amblyopia  of  more  than  one  form  is  said  to  be  produced 
by  malarial  poisoning :  some  cases  have  recovered  under 
quinine.  Loss  of  sight  from  malarial  fever  must  not  be 
confused  with  blindness  due  to  the  quinine  administered 
for  its  cure  (p.  439). 

Relapsing  fever  is  sometimes  followed,  during  convales- 
cence, by  inflammatory  symptoms  with  opacities  in  the 
vitreous,  cyclitis,  with  or  without  iritis  ;  recovery  takes 
place.  These  cases  are  commoner  in  some  epidemics  than 
in  others.  In  a  large  outbreak  Lubinski  saw  no  eye  cases 
in  patients  under  twenty  years  of  age,  and  none  in  females. 

Epidemic  cerebro-spinal  meningitis  also,  in  a  few  cases, 
gives  rise  to  acute  choroiditis,  with  pain,  chemosis,  and 
great  tendency  to  rapid  exudation  of  lymph  into  the  vit- 
reous and  anterior  chambers,  and  often  leading  to  disor- 
ganization of  the  eye  and  blindness.*  It  is  believed  that 
the  inflammation  may  extend  to  the  eye  along  the  optic 
nerve,  or  it  may  occur  independently  in  the  brain  and  the 
eye.  Deafness  from  disease  of  the  internal  ear  is  even 
commoner  than  the  eye  disease. 

Purpura  has  been  observed  in  a  few  cases  to  be  accom- 
panied by  retinal  or  subretinal   hemorrhages ;   they   are 

1  Possibly  a  few  of  the  cases  in  which  similar  eye  conditions  are  seen 
without  apparent  cause  may  be  the  accompaDiments  of  slight  and  un- 
recognized meningitis. 


436  ETIOLOGY. 

sometimes  perivascular  and  linear,  and  in  other  cases  form 
large  blotches.  They  have  also,  but  rarely,  been  found  in 
Scurvy.  Ecchymosis  may  also  be  seen  in  and  around  the 
eyelids  in  scurvy.  In  that  form  of  scurvy  which  occurs 
in  infants,  especially  rickety  infants,  extravasation  may 
also  occur,  as  Dr.  Barlow  has  shown, ^  into  the  orbit,  and 
probabl}"  between  the  roof  of  the  orbit  and  its  very  loosely, 
attached  periosteum,  thus  causing  proptosis  and  swelling 
of  the  lids,  as  well  as  discoloration. 

In  Pyaemia  one  or  both  eyes  may  be  lost  by  septic  emboli 
lodging  in  the  vessels  of  the  choroid  or  retina,  and  setting 
up  suppurative  panophthalmitis.  The  symptoms  are  swell- 
ing of  the  lids,  loss  of  sight,  congestion,  especially  of  the 
perforating  ciliary  vessels.  Fig.  27,  chemosis,  discoloration, 
and  dulness  of  aqueous  and  iris.  There  may  or  may  not 
be  some  protrusion  and  loss  of  mobility,  and  conjunctival 
discharge.  Pain,  sometimes  ver}^  severe,  may  be  almost 
absent ;  probably  its  presence  indicates  rise  of  tension.  A 
yellow  reflex  is  often  seen  from  the  vitreous.  The  eyeball 
generally  suppuratesifthepatient  live  long  enough.  Some- 
times both  eyes  are  affected,  together  or  with  an  interval. 
In  cases  of  Septicaemia  abundant  retinal  hemorrhages  of 
large  size  may  occur  in  both  eyes  ;  they  come  on  a  few 
days  before  death,  and  are  thus  of  grave  significance.  As 
they  are  not  present  in  typhoid  and  other  fevers  of  corre- 
sponding severity,  their  presence  is  sometimes  an  aid  in 
differential  diagnosis.^ 

Lead  poisoning  is  an  occasional  cause  of  optic  neuro- 
retinitis  leading  to  atrophy,  of  atrophy  ensuing  upon 
chronic  amblyopia,  and  of  rapid,  usually  transient,  ambly- 
opia.   The  two  former  are  the  most  common  ;  the  atrophy, 

^  Med.-Chir.  Trans.,  vol.  Ixvi.,  and  Keating's  Eucyclopoedia  of  Dis- 
eases of  Children,  article  "  Scurvy." 
2  Gowers,  Medical  Ophthalmoscopy,  2d  ed.,  p.  255. 


ETIOLOGY.  437 

whether  primary  or  consecutive  to  papillitis,  is  generally 
accompanied  by  very  marked  shrinking  of  retinal  arteries, 
and  great  defect  of  sight  or  complete  blindness ;  it  is  gen- 
erally symmetrical,  but  one  eye  may  precede  the  other. 
Other  symptoms  of  lead  poisoning,  usually  chronic,  but 
occasionally  acute,  are  nearly  always  present.  Care  must 
be  taken  not  to  confuse  albuminuric  retinitis  from  kidney 
disease  induced  by  lead  with  the  changes  here  alluded  to, 
which  are  due  in  some  more  direct  manner  to  the  influence 
of  the  metal. 

The  deposition  of  lead  upon  corneal  ulcers  has  been  re- 
ferred to  at  p.  150. 

Alcohol. — Some  observers  still  hold  that  alcohol,  espe- 
cially in  the  form  of  distilled  spirits,  may  cause  a  particular 
form  of  symmetrical  amblyopia,  the  so-called  amblyopia 
'potatorum.  Optic  neuritis  and  paralyses  of  various  single 
oculo-motor  nerves  are  described  by  Thomsen  as  occurring 
in  cases  of  alcoholic  paralysis.  The  difficulty  of  arriving 
at  the  truth  depends  chiefly  upon  the  fact  that  most  drink- 
ers are  also  smokers,  and  that  tobacco,  whether  smoked  or 
chewed,  is  allowed  by  all  authorities  to  be  one  of  the  causes, 
or,  as  most  now  hold,  the  sole  cause,  of  a  similar  disease. 
The  question  whether  alcohol  directly  causes  disease  of  the 
optic  nerves  will  not  be  settled  until  observers  are  much 
more  careful  than  they  have  hitherto  been  to  record  as 
typical  cases  of  alcoholic  amblyopia  only  those  in  which 
the  patient  does  not  use  even  the  smallest  quantity  of  to- 
bacco in  any  shape. 

Tobacco Whatever  may  be  the  truth,  and  it  is  confess- 
edly difficult  to  arrive  at,  as  to  the  direct  influence  of 
alcohol,  and  of  the  various  substances  often  combined  with 
it,  there  is  no  doubt  whatever  that  tobacco,  whether  smoked 
or  chewed,  does  act  directly  on  the  optic  nerves,  and  in 
.  such  a  manner  as  to  give  rise  to  definite,  and  usually  very 
characteristic  symptoms.    The  amblyopia  seldom  comes  on 


438  ETIOLOGY. 

until  tol)acco  has  been  iiHcd  for  many  3'ears.  The  quantity 
needed  to  cause  symptoms  is,  cseteris  paribus,  a  matter  of 
idiosyncrasy,  and  ver}"  small  doses  may  produce  the  disease 
in  men  who  in  other  respects,  also,  are  unable  to  tolerate 
laru'c  quantities  of  the  drug.  Predisposing  causes  exert  a 
very  important  influence;  amongst  these  are  to  be  specially 
noted  increasing  age;  nervous  exhaustion  from  overwork, 
anxiety,  or  loss  of  sleep  ;  chronic  dyspepsia,  whether  from 
drinking  or  other  causes;  and  probably  sexual  excesses 
and  exposure  to  tropical  heat,  or  light.  A  large  propor- 
tion of  the  patients  drink  to  excess,  and  thus  make  them- 
selves more  susceptible  to  tobacco,  both  by  injuring  the 
nervous  system  and  the  stomach.  But  some  remarkable 
cases  are  seen  in  men  who  have  for  long  been  total  ab- 
stainers, in  others  who  have  lately  become  abstainers  with- 
out lessening  their  tobacco,  and  in  yet  others  who  are 
strictly  moderate  in  alcohol,  are  in  robust  health,  and  in 
whom  increasing  age  is  the  only  recognizable  predisposing 
cause.  The  strong  tobaccos  produce  the  disease  far  more 
readily  than  the  weaker  sorts,  and  chewing  is  more  dan- 
gerous than  smoking.  Probably  alcohol  in  very  moderate 
doses  counteracts,  rather  than  increases,  the  injurious  effect 
of  tobacco  upon  the  nervous  system  and  optic  nerves 
(Hutchinson). 

The  vapor  of  Bisulphide  of  Carbon,  if  inhaled  in  a  con- 
centrated form  and  for  long  periods,  produces  at  first 
excitement,  then  general  and  severe  loss  of  nerve  powder, 
with  extreme  mental  and  muscular  debility  and  impotence. 
In  some  of  the  cases  the  sight  fails  chiefly  in  the  centre  of 
the  field,  central  scotoma,  with  haze  and  pallor  of  the  discs, 
chronic  neuritis.  The  cases  are  met  with  either  in  India- 
rubber  works  or  oil-mills,  in  both  of  which  the  bisulphide 
is  largely  used.^ 

1  For  full  particulars,  see  Trans.  Ophth.  Soc.,vol.  v.  pp.  149-175 
(1885).     Another  case  is  reported  by  Gunn,  ibid.,  vi.  372  (1886). 


ETIOLOGY.  439 

Quinine,  taken  in  very  large  do?c?,  at  short  interval?,  has 
in  a  few  cases  caused  serious  visual  symptoms.  Sight  in 
both  eyes  may  be  totally  lost  for  a  time,  but  recoverv,  more 
or  less  perfect,  takes  place  eventually,  sometimes  in  a  ^ew 
days,  sometimes  not  for  months.  There  is  a  great  contrac- 
tion of  the  visual  field  even  after  perfect  recovery  of  cen- 
tral vision  ;  the  discs  are  pale  and  the  retinal  arteries 
extremely  diminished.  The  symptoms  are  therefore  those 
of  almost  arrested  supph^  of  arterial  blood  to  the  retina. 

Kidney  disease. — The  common  and  well-known  retino- 
neuritis  associatied  with  renal  albuminuria,  and  of  which 
several  clinical  types  are  found,  has  been  already  described. 
It  need  only  be  noted  that  the  disease  is  commonest  with 
chronic  granular  kidneys  and  in  the  kidney  disease  of 
pregnancy,  but  that  it  is  also  seen  in  the  chronic  forms  fol- 
lowing acute  nephritis  and  in  lardaceous  disease,  and  that 
children  suffering  from  chronic  renal  disease  seem  as  liable 
to  it  as  adults.  Retinitis  with  renal  albuminuria  is  usually 
a  sign  that  the  kidney  disease  is  far  advanced,  and  the 
prospect  of  life  very  bad.  According  to  Miley,  hospital 
patients  seldom  live  more  than  six  months  after  the  onset 
of  the  retinitis  (Op// ^/?.  Soc.  Trans.,  viii.  132).  C.  S.  Bull 
finds  that  the  average  duration  of  life  is  somewhat  longer, 
according  to  returns  from  patients  of  all  classes.  There  is 
no  doubt  that  the  prospect  of  life  for  patients  who  are  able 
to  liv^e  carefully  is  considerably  better  than  for  others.  It 
seems  likely  that  there  is  also  a  group  of  cases  in  which 
the  retinal  change  precedes  the  signs  of  kidney  disease, 
these  signs  appearing  later.  Detachment  of  the  retina  is 
an  occasional  result  in  extreme  cases.  The  prognosis  as 
regards  vision  is  best  in  the  cases  depending  on  albuminuria 
of  pregnancy  The  retinal  oedema  and  exudation  are 
probably  caused  by  the  blood  state  ;  but  the  disease  of  the 
small  bloodvessels  and  the  cardiac  hypertrophy,  no  doubt, 
add  to  and  complicate  the  changes.     Indeed,  the  different 


440  ETIOLOGY. 

types  of  retinal  disease  v\  hicii  are  met  probably  depend  in 
great  measure  on  the  varying  parts  played  by  the  three 
factors  alluded  to.  The  failure  of  the  sight  caused  by 
albuminuric  retinitis  has  often  led  to  the  correct  diagnosis 
of  cases  which  had  been  treated  for  dyspepsia,  headache, 
or  "  biliousness." 

Diabetes  sometimes  causes  cataract.  In  young  or  middle- 
aged  patients  the  cataract  usually  forms  quickly,  and  is  of 
course  soft.  As  it  is  always  symmetrical,  the  rapid  forma- 
tion of  double,  complete  cataract,  at  a  comparatively  early 
age,  should  always  lead  to  the  suspicion  of  diabetes.  In 
old  persons  the  progress  of  diabetic  cataract  is  much  slower, 
and  often  shows  no  peculiarities.  The  relation  of  the  len- 
ticular opacity  to  the  diabetes  has  not  been  satisfactorily 
explained ;  the  presence  of  sugar  in  the  lens,  the  action  of 
sugar  or  its  derivatives  dissolved  in  the  aqueous  and  vitre- 
ous, the  abstraction  of  water  from  the  lens  owing  to  the 
increased  density  of  the  blood  ;  and,  lastly,  degeneration  of 
the  lens  from  the  general  cachexia  attending  the  disease, 
have  all  been  oflTered  in  explanation.  It  is  important  to 
know  that  diabetic  cataract  sometimes  disappears  entirely 
if  the  health  improves,  the  lens  completely  clearing  up.^ 
In  a  few  cases  retinitis  occurs :  sometimes  with  great  oedema 
and  copious,  probably  capillary,  hemorrhages  into  the  retina 
and  vitreous,  in  other  cases  with  numerous  white  patches, 
but  no  oedema.  Plastic  iritis  sometimes  occurs  in  diabetes 
both  with  and  without  previous  operation ;  Schirmer 
draws  attention  to  the  importance  of  examining  the  urine 
for  sugar  in  cases  of  intractable  iritis.  Central  amblyopia 
from  disease  of  the  optic  nerves  has  also  been  observed, 
even,  it  is  said,  in  patients  who  were  not  smokers.^ 

1  See  cases  reported  in  the  Trans.  Opbtlialmological  Soc.,  vol.  v.  p. 
107  (18S5). 

2  See  a  paper  by  Dr.  Edmunds  and  the  author,  Trans.  Ophth.  See., 
vol.  iii.,  1883.     A  doubtful  case  in  a  woman  is  recorded  in  t^e  same 


ETIOLOG  Y.  441 

LeucocythaBmia  is  often  accompanied  by  retinal  hemor- 
rhages, less  commonly  by  whitish  spots  bordered  by  blood, 
and  consisting  of  white  corpuscles  ;  these  spots  may  be 
thick  enough  to  project  forward.  Occasionally  there  is 
general  haziness  of  the  retina.  In  severe  cases  the  whole 
fundus  is  remarkably  pale,  whether  there  be  other  changes 
or  not.^     The  changes  are  usually  symmetrical. 

Progressive  pernicious  anaemia  is  marked  by  a  strong 
tendency  to  retinal  hemorrhages;  these  are  usually  grouped 
chiefly  near  the  disc,  and  are  striated  (Gowers).  White 
patches  are  also  common,  and  occasionally  well-marked 
neuritis  occurs.  I  have  seen  hemorrhages  of  different  dates, 
and  in  one  case,  shown  to  me  by  Dr.  Sharkey,  there  had 
evidently  been  a  large  extravasation  from  the  choroid  at  an 
earlier  period.  The  disc  and  fundus  participate  in  the 
general  pallor. 

Heart  disease  is  variously  related  to  changes  in  the  eyes 
and  alterations  of  sight.  Aortic  incompetence  often  pro- 
duces visible  pulsation  of  the  retinal  arteries.  This  pulsa- 
tion often  differs  from  that  seen  in  glaucoma  in  extending 
far  beyond  the  disc,  and  in  not  being  so  marked  as  to  cause 
complete  emptying  of  the  larger  vessels  during  the  diastole. 
In  glaucoma  the  pulsation  is  confined  to  the  disc.  The 
difference  is  explained  by  the  different  mode  of  production 
in  the  two  cases  :  in  the  one,  incomplete  closure  of  the  aortic 
orifice  lowers  the  pressure  in  the  whole  blood-column  during 
the  diastole,  and  allows  a  reflux  of  blood  from  the  eye ;  in 
the  other  heightened  intra-ocular  tension,  telling  chiefly  on 

paper;  and  another,  also  not  completely  satisfactory,  by  Samuel,  in 
Hirsehberg's  Centralblatt,  18S2,  p.  202.  Paper  by  Moore,  New  York 
Med.  Journ.,  18S8. 

'  For  a  full  account  of  the  changes  see  Gowers'  Medical  Ophthalmo- 
scopy. Dr.  Sharkey  has  shown  me  a  case  with  diffuse  retinitis,  very 
numerous  punctiform  hemorrhages,  chiefly  peripheral,  and  dilatation, 
with  extreme  tortuosity  of  the  veins. 

19* 


442  ETIOLOGY. 

the  comparatively  yielding  tissues  of  the  optic  disc,  in- 
creases the  resistance  to  the  entrance  of   arterial    blood. 
Valvular  disease  of  the  heart  is  generally  present  in  the 
case  of  sudden  lasting  blindness  of  one  eye,  clinically  diag- 
nosed as  embolism  of  the  arteria  centralis  retinae ;  but  in 
some  of  these  thrombosis  of  the  artery  or  of  its  companion 
vein,  or  blocking  of  the  internal  carotid'  and  oi)htiialmic 
arteries,  has  been  found  poat-mortem.     Brief   temporary 
failure,  or  even  loss,  of  sight  may  occur  in  the  subjects  of 
valvular  heart  disease,  and  in  some  persons  who  are  liable 
to  recurring  headache  (see  Megrim).    Repeated  attacks  of 
this  kind  sometimes  lead  to  permanent  blindness  of  one  eye, 
and  atrophy  of  the  disc  comes  on  ;  possibly  repeated  tempo- 
rary failures  of  retinal  circulation  at  length  give  rise  to 
thrombosis.    In  another  group  of  cases  which  needs  investi- 
gation, sight  fails  during  successive  pregnancies  or  lacta- 
tions, recovering  between  times;  some  of  these  may  be 
cases  of  renal  retinitis  ;  others  may  be  mere  accommodative 
asthenopia.     It  is  probable  that  high  arterial  tension  pre- 
disposes to  intra-ocular  hemorrhage  in  cases  where  the  small 
vessels  are  unsound,  and  that  the  frequent  association  of 
retinal  hemorrhage  with  cardiac  disease  is  thus  explained. 
Tuberculosis  is  sometimes  accompanied  by  the  formation 
of  tubercles  in  the  choroid.      These  may  occur  in  acute 
miliary  tuberculosis,  whether  the  meninges  be  involved  or 
not,  but  owing  to  the  difficulty  of  thorough  ophthalmo- 
scopic examination  in  such  patients,  and  the  frequently 
very  small  size  of  the  choroidal  growths,  they  are  much 
more  often  seen  after,  than  before  death.     Chronic  tuber- 
cular tumors  of  the  brain  may  be  accompanied  by  tubercles 
of  slow  growth  and  larger  size  in  the  choroid,  and  occasion- 
ally these  attain  such  dimensions,  and  cause  such  active 

1  Gowei's'  Medical  Ophthalmoscopy,  p.  29. 


ETIOLOGY.  443 

symptoms,  as  to  simulate  malifrnant  tumors.*  It  is  also 
probable  that  certain  cases  of  localized  choroidal  exudation, 
not  accompanied  by  serious  general  symptoms  or  by  in- 
flammatory symptoms  in  the  eye,  may  be  of  tubercular 
nature. 

Barlow^  has  seen  tubercles  in  the  choroid  posf-morfem,  in 
16  cases;  in  13  with,  3  without,  tubercular  meningitis. 
Sometimes  they  took  the  form  of  extremely  minute  dots, 
"  tubercular  dust."  In  44  children  who  died  of  tubercular 
disease,  42  showing  miliary  tubercles  in  the  meninges,  Dr. 
Money^  found  tubercles  in  the  choroid  of  one  or  both  eyes 
in  14.' 

Rheumatism. — In  acute  rheumatism  Dr.  Barlow  informs 
me  that  he  has  more  than  once  seen  well-marked  conges- 
tion of  the  eyes  and  photophobia ;  but  neither  iritis  nor 
other  inflammatory  changes  occur.  The  subjects  of  chronic 
rheumatism  are,  however,  subject  to  relapsing  inflammation 
of  the  eye,  usually  taking  the  form  of  iritis,  but  sometimes 
falling  entirely  on  the  scleral  or  episcleral  tissues,  whilst  in 
others,  less  common,  the  changes  are  apparent!}^  confined 
to  tlie  conjunctiva — rheumatic  conjunctivitis.  But  how- 
ever superficial  the  inflammation,  or  congestion,  may  be, 
there  is  no  muco-purulent  discharge.  Some  of  these  patients 
give  a  history  of  acute  articular  rheumatism  as  the  starting- 
point  of  their  chronic  troubles,  others  of  a  prolonged  sub- 
acute attack,  lasting  for  many  months,  whilst  in  others, 
again,  the  articular  symptoms  have  never  been  severe.  In 
yet  another  series  a  liability  to  fascial  or  muscular  rheu- 
matism, or  to  recurrent  neuralgia  from  exposure  to  cold 
or  damp,  are  the  only  "  rheumatic"  symptoms  of  which 

1  For  interesting  cases  of  and  remarks  on  choroidal  tuberculosis  in  its 
various  forms  and  relations,  see  communications  by  Mackenzie,  Barlow, 
Couplaud,  and  others  in  Traus;  Ophth.  Soc,  vol.  iii.  p.  119  et  seq.  (Oct. 
188-2). 

*  Barlow,  Ibid.,  p.  132.  »  Money,  Lancet,  1S83,  ii.  81?. 


444  ETIOLOGY. 

a  history  is  given  ;  in  some  of  these  the  neuralgia  is  prob- 
ably gouty.  It  is  to  be  remembered  that  the  eye  is  now 
and  then  the  first  part  to  be  attacked  by  an  inflammation 
which  later  events  show  to  be  clearly  related  to  rheumatism 
or  gout. 

Gonorrhoeal  rheumatism  is  not  unfrequently  the  starting- 
point  of  relapsing  iritis  and  the  other  conditions  named 
above,  as  well  as  of  chronic  relapsing  rheumatism.  Rheu- 
matic iritis  occurring  for  the  first  time  with  gonorrhoeal 
rheumatism  is,  in  my  experience,  more  often  symmetrical 
than  other  forms  of  arthritic  iritis,  or  than  the  later  attacks 
of  iritis  in  the  same  patient ;  a  fact  which  sometimes  makes 
the  distinction  between  rheumatic  and  syphilitic  iritis  diffi- 
cult. 

This  statement  is  based  on  records  of  104  cases  of  iritis  with 
well-marked  rheumatic  symptoms, and  (3  with  gonorrhceabutno 
rheumatism,  in  all  of  which  syphilis  was,  so  far  as  possible,  ex- 
cluded, [a]  In  34  of  this  series  the  first  attack  of  iritis  came  on 
during,  or  very  soon  after,  gonorrhoeal  rheumatism  ;  and  in  ex- 
actly one-half  of  these  the  iritis  was  double.  In  6  others 
(making  40  in  all)  there  were  iritis  and  gonorrhoea,  but  no  rheu- 
matism ("gonorrhoeal  iritis"),  and  here  the  proportions  were 
the  same,  (h)  In  the  remaining  70  cases  the  first  iritis  had 
no  relation  to  gonorrhoea;  and  in  the  subseries  the  attackwas 
single  in  56  and  double  in,  at  the  most,  13  (two  or  three  being 
doubtful),  or  about  one-fifth.  No  coi-responding  difference  ob- 
tained in  regard  to  relapses,  the  vast  majority  of  the  recurrent 
attacks  in  both  subgroups  (a  and  h)  aft'ecting  only  one  eye  at 
a  time. 

Gonorrhceal  iritis. — Some  cases  of  gonorrhoeal  iritis  have 
been  described,  in  which  there  is  iritis  due  to  gonorrhoea 
without  arthritis  being  actually  present.  Probably  in  these 
cases  the  iritis  is  the  first  indication  of  gonorrhoeal  rheu- 
matism. A  variety  of  quietconjunctivitis,  not  due  to  infec- 
tion, has  also  been  described  without  pain,  and  hardly  any 
discharge  (Despagnet  and  others). 


ETIOLOGY.  4  45 

Rheumatic  in  flam  mat  ion  of  the  conjunctival  or  scleral 
type  occurring  in  gonorrhoea  must  be  carefully  distinguished 
from  purulent  ophthalmia  due  to  infection  with  gonorrhceal 
pus. 

In  some  cases  of  articular  rheumatism  in  infants  suffer- 
ing from  purulent  ophthalmia  the  arthritis  is  believed  to 
be  gonorrhceal,  but  derived  from  the  conjunctiva  instead 
of  the  urethra.^ 

It  is  believed  that  rheumatism  is  the  cause  of  some  cases 
of  non-suppurating  orbital  cellulitis,  and  of  relapsing  epi- 
scleritis. Rheumatism  is  also  believed  to  cause  some  other 
of  the  ocular  paralyses. 

Gout Gouty  persons  are  not  very  infrequently  the  sub- 
jects of  recurrent  iritis  indistinguishable  from  that  which 
occurs  in  rheumatism.  Rheumatism  and  gout  seem  some- 
times so  mixed  that  it  is  not  always  possible  to  assign  to 
each  its  right  share  in  the  causation  of  iritis  ;  but  that  the 
subjects  of  true  "chalk  gout"  are  liable  to  relapsing  iritis 
is  undoubted.  There  is,  on  the  whole,  more  tendency  to 
insidious  forms  of  iritis  in  gout  than  in  rheumatism.  It  is 
also  generally  believed  that  the  subjects  of  gout,  or  persons 
whose  near  relatives  suffer  from  it,  are  particularly  subject 
to  glaucoma  ;  acute  glaucoma  was,  indeed,  the  "arthritic 
ophthalmia"  of  earlier  authors.  Hemorrhagic  retinitis  is 
also  commoner  in  gouty  persons  than  in  others  ;  it  may  be 
single  or  double,  and  is  to  be  distinguished  from  albumi- 
nuric retinitis.  It  has  also  been  observed  that  the  children 
or  descendants  of  gouty  persons,  w^ithout  being  themselves 
subject  to  gout,  are  liable,  in  early  adult  life,  to  an  insidi- 
ous form  of  irido-cyclitis,  which  sometimes  leads  to  serious 
consequences  ;^  both  eyes  are  likely  to  be  attacked  sooner 

1  Clement  Lucas,  Brit.  Med.  Journ.,  1885,  ii.  pp.  57  and  699  ;  Fen- 
dick,  ibid.,  p.  830  ;  Saswornitzky,  abstracted  in  Knapp's  Archives,  xv, 
232  (1886).  In  a  note  with  which  Mr.  Lucas  has  favored  me  he  sug- 
gests the  term  "  ophthalmic  rheumatism"  for  these  cases. 

2  Hutchinson,  Lancet,  Jan.,  1873. 


446  ETIOLOGY. 

or  later.  The  ca?es  in  this  Grronp  probably  seem  rarer  than 
they  are,  from  the  impossibility  in  many  instances  of  getting 
a  full  family  history. 

Several  different  clinical  types  may  be  recognized  in  the 
large  group  of  maladies  referred  to  in  this  section  under 
the  name  of  "  iritis."  Besides  cases  of  pure  iritis,  we  meet 
with  examples  of  cyclitis,  in  some  cases  with  increase,  in 
others  with  decrease,  of  tension  ;  in  other  groups  either  the 
sclerotic  or  conjunctiva  is  chiefly  affected,  true  "rheumatic 
ophthalmia"  without  iritis  ;  a  fourth  group  in  which  the 
pain  is  disproportionately  severe,  may  be  spoken  of  as  neu- 
ralgic, and  the  neuralgic  cases  are  marked  by  sudden  onset, 
short  duration,  and  great  frequency.  In  a  large  majority, 
however,  the  iris  is  the  headquarters  of  the  morbid  action. 
All  arthritic  eye  diseases  tend  strongly  to  relapse  ;  they 
usually  attack  only  one  eye  at  a  time,  though  both  suffer 
sooner  or  later;  and  they  are  all  much  influenced  by  condi- 
tions of  weather,  being  commonest  in  spring  and  autumn. 

The  strumous  condition  is  a  fruitful  source  of  superficial 
eye  diseases,  which  are  for  the  most  part  tedious  and  re- 
lapsing, are  often  accompanied  by  severe  irritative  sj^mp- 
toms,  but,  as  a  rule,  do  not  lead  to  serious  damage.  The 
best  types  are  :  (1)  the  different  varieties  of  ophthalmia 
tarsi ;  (2)  all  forms  of  phlyctenular  ophthalmia,  "  pustular" 
or  "herpetic"  diseases  of  the  cornea  and  conjunctiva  ;  (3) 
many  superficial  relapsing  ulcers  of  cornea  in  children  and 
adolescents,  though  not  distinctly  phlyctenular  in  origin, 
are  certainly  strumous  ;  (4)  many  of  the  less  common,  but 
very  serious,  varieties  of  cyclo-keratitis  in  adults  occur  in 
connection  with  lowered  health,  susceptibility  to  cold,  and 
sluggish  but  irritable  circulation,  if  not  with  decidedly 
scrofulous  manifestations. 

Leprosy  may  have  its  seat  in  almost  any  part  of  the  eye, 
but  it  usually  occurs  first  in  the  superficial  parts,  and  leads 
to  ectropion,  with  exposure  of  the  cornea,  and  xerosis  of 


ETIOLOGY.  44T 

the  conjunctiva  ;  or  there  may  be  a  deposit  of  leproniata 
in  the  cornea,  leading  to  its  perforation  and  to  panophthal- 
mitis ;  iritis  and  cyclitis  may  also  occur,  and  leprous  inva- 
sion of  the  retina  has  also  been  seen. 

Entozoa  sometimes  come  to  rest  and  develop  in  the  eye 
or  orbit.  The  commonest  intra-ocular  parasite  is  the  cijhU- 
cercufi  cellulosae;  it  is  excessively  rare  in  this  country,  but 
commoner  on  the  Continent.  The  cysticercus  may  be  found 
either  beneath  the  retina,  in  the  vitreous,  or  upon  the  iris, 
and  may  sometimes  be  recognized  in  each  of  these  positions 
by  its  movements.  The  parasite  has  been  successfully  ex- 
tracted from  the  vitreous ;  when  situated  on  the  iris  its 
removal  involves  an  iridectomy.  Sometimes  it  develops 
under  the  conjunctiva,  where  I  have  seen  it  set  up  suppu- 
rative inflammation.  The  echinococciis  hydatid  with  mul- 
tiple cysts  may  develop  to  a  large  size  in  the  orbit  and 
cause  much  displacement  of  the  eyeball. 

B.  Eye  disease,  or  eye  symptoms,  indicative  of  local  dis- 
ease at  a  distance. 

Megrim  is  well  known  to  be  sometimes  accompanied, 
or  even  solely  manifested,  by  temporary  disorder  of  sight. 
This  generally  takes  the  form  of  a  flickering  cloud,  "  flit- 
tering scotoma"  of  German  authors,  with  serrated  borders, 
which,  beginning  near  the  centre  of  the  field,  spreads  eccen- 
trically, so  as  to  produce  a  large  defect  in  the  field,  a  sort 
of  hemianopsia ;  the  borders  of  the  cloud  may  be  brilliantly 
colored.  It  is  referred  to  both  eyes,  and  is  visible  when 
the  lids  are  closed.  The  attack  lasts  only  a  short  time,  and 
perfect  sight  returns.  In  many  patients  this  amblyopia  is 
the  precursor  of  a  severe  sick  headache,  but  in  others  it 
constitutes  the  whole  attack  ;  it  scarcely  ever  follows  the 
headache.  Less  definite  and  characteristic  symptoms,  dim- 
ness, cloudiness,  and  muscae,  are  complained  of  by  some 
patients.  Recurrent  paralysis  of  the  third  nerve  has  sev- 
eral times  been  ascribed  to  megrim. 


448  ETI 0  LOGY . 

Neuralgia  of  the  fifth  nerve,  especially  of  its  first  divi- 
sion, in  a  few  cases  precedes  or  accompanies  failure  of  sight 
in  the  corresponding  eye,  with  neuritis  or  atrophy  of  the 
disc.  A  liability  to  neuralgia  of  the  face  and  head  is  not 
unfrequently  observed  in  persons  who  subsequently  suffer 
from  glaucoma.  Intense  neuralgic  pain  in  the  face  or  head 
sometimes  causes  dimness  of  sight  of  the  same  eye  whilst 
the  pain  lasts.  The  old  belief  that  injury  to  branches  of 
the  fifth  nerve  can  cause  amaurosis  is  not  borne  out  by 
modern  experience,^  ii^jury  to  the  optic  nerve  by  fracture 
of  the  skull  furnishing  the  true  explanation  of  such  cases. 

Sympathetic  ophthalmitis  is  the  only  known  instance  in 
which  inflammation  of  the  eyeball  is  caused  by  local  dis- 
ease of  an  independent  part. 

Diseases  of  the  central  nervous  system  may  be  shown 
in  the  eye  either  at  the  optic  disc,  papillitis  and  atrophy, 
or  in  the  muscles,  strabismus,  and  diplopia. 

The  diseases  which  most  often  cause  papillitis  are  intra- 
cranial tumors,  syphilitic  growths,  and  meningitis.  Abscess 
of  the  brain  and  softening  from  embolism  and  thrombosis 
less  commonly  cause  it,  and  cerebral  hemorrhage  scarcely 
ever.^  Papillitis  has  been  found  in  a  few  cases  of  acute 
and  subacute  myelitis:^  it  does  not  occur  in  spinal  menin- 
gitis. 

In  a  very  large  proportion.  Dr.  Gowers  thinks  at  least 
four-fifths,  of  all  the  cases  of  cerebral  tumor,  including 
syphilitic  growths,  optic  neuritis  occurs  at  some  period. 
The  severity  and  duration  of  the  neuritis  vary  much,  and 
probably  depend  in  many  cases  on  the  rate  of  progress,  as 

^  References  to  many  of  the  earlier  cases  supposed  to  prove  this  rela- 
tion between  the  fifth  and  optic  nerves  are  given  by  Brown-Sejuard  in 
Holmes's  System  of  Surgery,  od  *d.,  vol.  ii.  p.  206. 

2  A  case  by  Dr.  Bristowein  Trans.  Ophth.  See,  vol.  vi.  1SS6,  p.  363. 

3  Gowers,  loc.  cit.,  p.  161  ;  Dreschfeld,  Lancet,  Jan.  7,  1882  ;  and 
Sharkey  and  Lawford,  Trans.  Ophth.  Soc,  vol.  iv,  p.  232. 


ETIOLOGY.  449 

well  as  on  the  character  of  the  morbid  growth.  It  not 
uncommonly  sets  in  at  no  long  interval  before  death, 
whilst  in  other  cases  it  is  very  chronic.  There  is  not  much 
in  the  characters  or  course  of  the  papillitis  to  help  us  in 
the  localization  of  intracranial  tumor  ;  and  although  a  very 
high  degree  of  papillitis,  with  signs  of  great  obstruction  to 
the  retinal  circulation,  generally  indicates  cerebral  tumor, 
there  are  many  cases  in  which  the  presence  of  papillitis 
does  not  help  us  to  decide  the  nature  of  the  intracranial 
disease,  whether  tumor,  meningitis,  or  syphilitic  disease. 

Analyzing  96  cases  of  fatal  cerebral  tumor,  Edmunds  and 
Lawford  found  that  optic  neuritis  was  observed  in  19  of  41 
eases  where  the  disease  was  at  or  toward  the  convexity  (or  46 
per  cent.);  whilst  it  was  seen  in  41  of  55  cases  Avhere  the  dis- 
ease was  chiefly  at  the  base  (or  75  per  cent.).  In  43  cases  the 
tumor  was  either  in  the  basal  ganglia  or  the  cerebellum,  and 
in  37  of  these  (=  86  per  cent.)  optic  neuritis  occurred  ( Trans, 
of  Ophth.  Soc,  1884,  vol.  iv.  p.  172). 

Tumors  also  sometimes  cause  simple  optic  atrophy  by 
pressing  upon  or  invading  some  part  of  the  optic  fibres. 

Intracranial  syphilitic  disease  is  a  common  cause  of 
papillitis  ;  the  disease  being  either  a  gummatous  growth  in 
the  brain,  or  a  growth  or  thickening  beginning  in  the  dura 
mater,  or  basilar  meningitis.  The  prognosis  is  much  better 
than  in  cerebral  tumors  if  vigorous  treatment  be  adopted 
early  ;  indeed,  in  all  cases  of  papillitis  where  intracranial 
disease  is  diagnosed,  and  syphilis  even  remotely  possible, 
mercury  and  iodide  of  potassium  should  be  promptly  given. 

Meningitis  often  causes  papillitis,  but  in  this  respect 
much  depends  on  its  position  and  duration.  Meningitis 
limited  to  the  convexity,  whatever  its  cause,  is  seldom 
accompanied  by  ophthalmoscopic  changes  ;  on  the  other 
hand,  basic  meningitis  very  often  causes  neuritis. 

Amongst  16  cases  of  injury  to  the  head  ending  in  death 
Edmunds  and  Lawford  never  found  optic  neuritis  without 


450  ETIOLOGY. 

basic  nieiiincritis  ;  wlnlst  they  founrl  no  neuritis  wlien  the  dam- 
age was  limited  to  the  convexity  {OijJlUl  Soc.^  Oct.  188G). 

The  neuritis  in  basic  meningitis  is  probably  proportionate 
to  the  duration  and  intensity  of  the  intracranial  mischief, 
being  comparatively  slight  in  acute  and  rapidly  fatal  cases, 
whether  tuljercular  or  not.  In  tubercular  meningitis 
papillitis  is  very  common,'  and  its  occurrence  seems  espe- 
cially related  to  the  presence  of  inflammatory  changes 
about  the  chiasma  (Gowers)  ;  and  even  the  neuritis  occur- 
ring in  cases  of  cerebral  tumor  seems  often  to  be  caused  by 
secondary  meningitis  set  up  by  the  growth.^  In  a  form  of 
meningitis  in  young  children,  named  by  Drs.  Gee  and 
Barlow  "posterior  basic,"  optic  neuritis  is  infrequent, 
though  the  patients  often  live  some  littie  time.  When 
patients  recover  from  meningitis  the  neuritis  may  pass  into 
atrophy,  and  cause  amaurosis  ;  such  cases  are  well  known 
to  ophthalmic  surgeons;  it  is  probable  that  some  of  them 
may  be  instances  of  recovery  from  tubercular  meningitis. 
In  rare  cases  papillitis  occurs  with  severe  head  symptoms, 
ending  in  death,  but  without  microscopic  changes  in  the 
brain  or  membranes.  Microscopical  changes  in  the  brain 
substance,  justifying  the  term  cerebritis,  have  been  found 
in  one  such  case  by  Dr.  Sutton,  and  in  another  by  Dr. 
Stephen  Mackenzie.'  It  must  not  be  forgotten  that  optic 
neuritis  may  be  caused  by  various  altered  conditions  of 
the  blood  ;  and  that  it  is  occasionally  seen  without  any 
evidence  either  of  central  nervous  disease  or  of  blood 
changes. 

Hydrocephalus  rarely  causes  papillitis,  but  often  at  a 
late  stage  causes  atrophy  of  the    optic  nerves  from  the 

^  Garlick  found  it  in  23  of  20  fatal  cases,  Med.-Chir.  Trans.,  vol.  Ixii. 
Money  (loc.  cit.)  discovered  it  in  only  16  of  43  fatal  eases.  Slight 
papillitis  is  very  easily  overlooked  in  delirious  or  fretful  children. 

2  Edmunds  and  Lawford,  Trans,  of  Ophth.  Soc.,  iii.  138,  1883. 

8  Also  a  case  by  Dr.  Silk,  Brit.  Med.  Journ.,  May  26,  18S3. 


ETIOLOGY.  451 

pressure  of  the  distended  third  ventricle  on  the  chiasma. 
Dr.  Barlow  informs  rae  that  he  has  several  times  seen  a 
very  iiToss  form  of  choroiditis  endin.ir  in  immense  patches  of 
atrophy.     I  have  recorded  one  such  case,  and  seen  others. 

The  diseases  most  commonly  causing  atrophij  not  pre- 
ceded bij  papillilis  are  the  chronic  pro;^ressive  diseases  of 
the  spinal  cord,  especially  locomotor  ataxy.  The  atrophy 
in  these  cases  is  slowly  progressive,  double,  though  seldom 
beginning  at  the  same  time  in  both  eyes,  and  it  always  ends 
in  blindness,  although  sometimes  not  until  after  many 
years.  Similar  atrophy  sometimes  occurs  in  the  early 
stages  of  general  paralysis  of  the  insane,  but  chiefly  in 
cases  complicated  by  marked  ataxic  symptoms.  It  is  also, 
but  much  more  rarely,  seen  in  lateral  and  in  insular  scle- 
rosis. In  the  latter,  amblyopia  with  slight  neuritic 
changes  is  occasionally  seen,  and  sight  may  improve  or 
almost  recover  after  having  been  defective  for  some  time. 
In  cases  of  homonymous  lateral  hemiunopia  we  find  that 
sometimes  the  blind  half  of  the  field  is  separated  from  the 
seeing  half  by  a  straight  line  which  passes  through  the  fix- 
ation point  (Fig.  93),  whilst  more  commonly  this  dividing 
line  deviates  toward  the  blind  half  in  the  central  part  of 
the  field,  thus  leaving  a  small  central  area  of  perfect  vision. 
Terrier  has  suggested  that  in  the  former  cases  the  lesion 
is  probably  situated  in  the  tract,  and  that  in  the  latter  it 
lies  in  some  part  of  the  cortical  visual  centre. 

Motor  disorders  of  the  eyes. — Some  of  the  commoner 
causes  of  ocular  palsy  have  been  ah-eady  given.  It  may 
be  mentioned  here  that  basic  meningitis  often  causes  para- 
lysis of  one  or  more  of  the  ocular  nerves,  with  squinting, 
and  double  vision  if  the  patient  be  conscious  ;  and,  further, 
that  the  palsy  in  such  cases  often  varies,  or  appears  to 
vary,  from  day  to  day. 

Locomotor  ataxy  and  general  paralysis  of  the  insane  are 
sometimes  preceded  by  paralysis,  usually,  but  not  always, 


452  ETIOLOGY. 

temporary,  of  one  or  more  of  the  eye  muscles,  causing 
diplopia  ;  and  there  may  for  years  be  nothing  else  to  attract 
attention.  The  same  disease  may  also  be  ushered  in  by 
internal  ocular  paralysis.  The  most  frequent  variety  is 
loss  of  the  reflex  action  of  the  pupils  to  sensory  stimulation 
of  the  skin  and  to  light,  whilst  their  associated  action 
remains,  "reflex  iridoplegia ;"  when  shaded  and  lighted 
they  remain  absolutely  motionless,  but  they  dilate  when 
accommodation  is  relaxed  and  contract  when  it  is  in 
action  ("Argyll  Robertson  symptom"),^  This  phenome- 
non is  often,  though  by  no  means  always,  associated  with 
a  contracted  state  of  the  pupils,  and  hence  the  term 
"spinal  miosis"  is  often,  but  incorrectly,  used.  This  re- 
flex paralysis  of  the  iris  is  one  of  the  most  valuable  of  the 
early  signs  of  locomotor  ataxy.  We  do  not,  however,  yet 
know  how  often  it  may  occur  in  healthy  persons  or  without 
eventual  spinal  disease;  it  certainly  has  comparatively 
little  significance  in  old  persons  Recent  observations 
show  that,  at  least  in  general  paralysis  of  the  insane,  loss 
of  reflex  dilatation  to  sensory  stimulation  of  the  skin  is 
probably  the  earliest  pupillary  change  ^  The  comple- 
mentary symptom,  loss  of  associated,  with  retained  reflex, 
action  of  the  pupils,  has  not  been  fully  studied  Any  of 
the  other  internal  paralyses  may  also  in  certain  cases  occur 
as  precursors  of  ataxy.  Paralysis  of  one  third  nerve  coming 
on  with  hemiplegia  of  the  opposite  side  may,  but  does  not 
necessarily,  indicate  disease  of  the  crus  cerebri  on  the  side 
of  the  palsied  third  nerve.^  Ophthalmoplegia  externa  has 
been  already  mentioned ;  it  may  here  be  added  that  cases 
occur  in  which  this  condition  appears  to  be  "functional," 
in  which,  at  any  rate,  the  symptoms  come  on  quickly  and 

1  Argyll  Robertson,  Edinburgh  Med.  Journ.,  1869,  p.  703. 

2  Bevan  Lewis,  Trans.  Ophth.  Soc,  vol.  iii.,  1883. 

3  For  exceptions  see  Robin,  Troubles  Oculaires  dans  les  Maladies  de 
I'Entephale,  1880,  p.  95. 


ETIOLOGY.  453 

pass  ofif  completely,  recurring  perhaps  at  a  later  period  ; 
of  these  cases  I  have  seen  several  in  young  adults. 

Double  ophthalmoplegia  externa  is  the  extreme  type  of 
a  large  and  important  class  of  ocular  palsies,  to  which 
much  attention  has  been  given  recently,  characterized  by 
the  paralysis  of  certain  ???oueme??^s,  usually  associated  move- 
ments of  the  two  eyes,  not  of  the  muscles  supplied  by  a 
certain  nerve.  There  may  be,  e.  g.,  loss  of  power  of  both 
eyes  to  look  upward,  both  superior  recti,  or  loss  of  power 
to  look  to  the  right,  R.  external  and  L.  internal  rectus  ; 
and  yet  in  the  latter  case  the  L.  internal  rectus,  if  differ- 
ently associated,  as  with  the  R.  internal  during  conver- 
gence, may  act  perfectly  well.  Such  associated  paralyses 
are  explained  by  lesions,  usually  sclerotic,  occasionally 
tumor,  affecting  the  centres  for  certain  combined  move- 
ments, which  are  more  central  anatomically  and  higher 
physiologically  than  the  centres  of  origin  of  the  nerve 
trunks.  Cases  of  paralysis  of  both  third  or  both  sixth 
nerves,  and  also  of  complete  ophthalmoplegia,  are  some- 
times due  to  symmetrical  coarse  disease,  syphilitic  gum- 
mata,  for  instance,  of  the  affected  nerve  trunks.  The 
symptoms  in  all  the  cases  referred  to  in  this  paragraph 
may  be  temporary  or  permanent,  acute  or  chronic,  and 
caused  by  various  fine  or  coarse  anatomical  changes;  and 
they  are  frequently  associated  with  other  and  graver  ner- 
vous symptoms.  It  is  of  great  importance  in  cases  of 
multiple  and  associated  ocular  paralysis  to  make  out,  if  we 
can,  whether  the  symptoms  point  to  peripheral  disease 
(disease  of  nerve  trunks),  or  to  disease  of  the  nuclei  of 
origin  of  the  nerves,  or  to  lesion  of  the  centres  for  certain 
movements. 

Insular  (disseminated)  sclerosis  is  often  accompanied  by 
nystagmus,  characterized  by  irregularity,  both  of  the  am- 
plitude and  rapidity  of  the  movements. 

There  appears  to  be  an  intimate  relation  betweeii  the 


454  ETIOLOGY. 

occurrence  of  Convulsions  and  the  formation  of  lamellar 
cataract,  tliis  form  of  cataract  beini^  scarcely  ever  seen, 
except  in  those  who  have  had  fits  in  infancy.  A  very 
striking-  deformity  of  the  permanent  teeth  is  also  nearly 
always  present,  depending  upon  an  abruptly  limited  defi- 
ciency or  absence  of  the  enamel  on  the  part  furthest  from 
the  gum,  Fig.  163  (7).  The  teeth  affected  are  the  first 
molars,  incisors,  and  canines,  of  the  permanent  set.  The 
dental  changes  are  quite  different  from  those  which  are 
pathognomonic  of  inherited  syphilis,  although  mixed  forms 
are  sometimes  seen.  The  relation  between  the  conv^ulsions, 
the  cataract,  and  the  defective  dental  enamel  has  not  been 
satisfactorily  explained.  Mr.  Hutchinson  has  collected 
many  facts  in  favor  of  the  belief  that  the  dental  defect  is 
due  to  stomatitis  interfering  with  the  calcification  of  the 
enamel  before  the  eruption  of  the  teeth,  and  that  mercury 
is  the  commonest  cause  of  this  stomatitis.  On  this  hypoth- 
esis the  coincidence  of  the  dental  defect  and  the  cataract 
is  due  to  mercury  having  been  usually  prescribed  for  the 
infantile  convulsions  from  which  these  cataractous  children 
suff'er.  It  seems,  however,  reasonable  to  suppose  that  the 
defect  of  the  crystalline  lens  and  of  the  enamel,  both  of 
them  epithelial  structures,  maybe  caused  by  some  common 
influence;  although  the  facts  that  the  peculiar  teeth  are 
often  seen  without  the  cataract,  and  the  cataract  occa- 
sionally seen  with  perfect  teeth,  appear  to  weaken  this 
view.^ 

Hysterical  eye  symptoms  (see  pp.  272,  378). 

C.  Cases  in  which  the  eye  shares  in  a  local  process  af- 
fecting the  neighboring  parts. 

In  herpes  zoster  of  the  first  division  of  the  fifth  nerve 
the   eye   participates.     When    only  the  supra-orbital    or 

1  Mr.  Eilf^ar  Browne  conte-ids  that  in  lamellar  cataract  without  his- 
tory of  fits  the  teeth  are  usually  good.    Ophth.  Review,  v.  354  (18S6). 


ETIOLOGY.  455 

snpra-trcrhlear  branches  are  attacked  the  eyeball  usually 
escapes  or  is  only  superficially  conuested.  But  if  the 
eruption  occur  on  the  ]iarts  supplied  by  the  nasal  branch, 
i.  e.,  if  the  spots  extend  down  to  the  tip  of  the  nose,  there 
is  usually  inflammation  of  the  proper  tissues  of  the  eyeball, 
ulceration  or  infiltration  of  cornea,  and  iritis;  for  the  sen- 
sitive nerves  of  the  cornea,  iris,  and  choroid  are  derived, 
through  the  long-  root  of  the  ophthalmic  ganglion,  from 
the  nasal  branch.  Occasionally  the  eye  suffers,  however, 
when  the  nasal  branch  escapes.  The  pain  and  swelling  of 
the  herpetic  region  are  often  so  great  that  the  attack  gets 
the  name  of  "  erysipelas."  In  rare  cases  atrophy  of  the 
optic  nerve  and  paralysis  of  the  third  and  other  neighbor- 
ing nerves  occur  with  the  herpes.^ 

In  paralysis  of  the  first  division  of  the  fifth  the  cornea 
and  conjunctiva  are  anaesthetic;  the  cornea  may  be  touched 
or  rubbed  without  the  patient  feeling  at  all.  In  many 
cases  ulceration  of  the  cornea,  usually  uncontrollable  and 
destructive  in  character,  takes  place.  It  is  doubtful  whether 
this  is  due  directly  to  paralysis  or  irritation  of  trophic  fibres 
running  in  the  trunk  of  the  fifth,  or  indirectly  to  the  anaes- 
thesia.^ In  regaid  to  the  latter,  it  is  certain  that  the  loss  of 
feeling  (1)  allows  injuries  and  irritations  to  occur  unper- 
ceived,  and  (2)  by  removing  the  reflex  effect  of  the  sensory 
nerves  on  the  calibre  of  the  bloodvessel,  permits  inflamma- 
tion to  go  on  uncontrolled. 

In  paralysis  of  the  facial  nerve  the  eyelids  cannot  be 
shut  and  the  cornea  remains  more  or  less  exposed.  When 
a  strong  effort  is  made  to  close  the  lid  the  eyeball  rolls 
upward  beneath  the  upper  lid.     Epiphora  is  a  common 

^  A  useful  paper  on  facial  herpes  Avith  many  references  by  Mr. 
Jessop,  is  published  in  vol.  vi.  of  the  Ophtbalmological  Society's 
Transactions,  18S6. 

2  Gowers  considfrs  it  due  more  to  irritation  of  the  nerve  than  to  the 
ana&sthesia.    Diagnosis  of  Diseases  of  Bnann,  p.  90. 


456  ETIOLOGY. 

result  of  facial  palsy.  Sev'ere  ulceration  of  the  cornea 
may  result  from  the  exposure. 

Paralysis  of  the  cervical  sympathetic  causes  some  nar- 
rowing of  the  palpebral  fissure  from  slight  drooping  of  the 
upper  lid,  apparent  recession  of  the  eye  into  the  orbit,  and 
more  or  less  miosis  from  paralysis  of  the  dilator  of  the 
pupil.  No  changes  are  observed  in  the  calibre  of  the 
bloodvessels  of  the  eye  or  in  the  secretion  of  tears,  The 
pupil  is  said  to  be  less  contracted  after  division  of  the  sym- 
pathetic trunk  than  when  the  trunk  of  the  fifth,  and  with 
it  the  oculo-sympathetic  fibres,  is  cut,  and  knowledge  of 
this  may  be  now  and  then  useful  in  diagnosis. 

In  exophthalmic  g-oitre,  Graves's  disease,  the  eyeballs 
are  too  prominent,  and  the  protrusion  is  almost  invariably 
bilateral,  though  not  unfrequently  greater  on  the  right 
sido.  It  is  often  apparently  increased  in  slight  cases  by  an 
involuntary  elevation  of  the  upper  lids  when  looking  for- 
ward, and  by  the  lids  not  following  the  cornea  as  they 
should  do  when  the  patient  looks  down. 

In  severe  eases  the  proptosis  may  be  so  great  as  to  pre- 
vent full  closure  of  the  lids,  and,  in  these,  dangerous  ulcer- 
ation of  the  cornea  is  to  be  feared.  In  such  cases  it  is 
beneficial  to  shorten  the  palpebral  fissure  by  uniting  the 
borders  of  the  lids  at  the  outer  canthus,  or  even  to  unite 
the  lids  in  their  whole  length  (p.  389).  Xo  changes  are 
present  in  the  fundus  excepting  sometimes  dilatation  of 
arteries  and  spontaneous  arterial  pulsation.  The  seat  of 
the  lesion  causing  this  peculiar  malady  is  not  yet  known. 
It  has  been  generally  supposed  to  be  due  to  some  morbid 
condition  of  the  sympathetic,  but  recent  speculations  point 
to  a  localized  central  lesion,  probably  in  the  medulla  ob- 
longata, as  being  more  likely.^ 

^  See  an  able  paper  by  Dr.  W.  A.  Fitz-Gerald  in  the  Dublin  Journ. 
Med.  Sci.  for  March  and  April,  1883. 


ETIOLOGY.  457 

Erysipelas  of  the  face  sometimes  invades  the  deep  tissues 
of  the  orbit  and  causes  blindness  by  affecting  the  optic 
nerve  and  retina;  on  recovery  the  eye  is  found  to  be  blind 
and  the  ophthalmoscope  shows  either  simple  atrophy  of 
the  disc  or  signs  of  past  retinitis  also.  Other  forms  of 
orbital  cellulitis  may  lead  to  the  same  result. 

Note  on  the  teeth  in  inherited  syphilis,  with  description 
of  Fig.  163. — None  of  the^iry^  set  of  teeth  are  character- 
istically altered,  though  the  incisors  frequently  decay  early. 

In  the  permanent  set  only  two  teeth,  the  central  upper 
incisors,  are  to  be  relied  upon  ;  but  the  other  incisors,  both 
upper  and  lower,  and  the  first  molars,  are  often  deformed 
from  the  same  cause.  The  characteristic  change  in  the 
upper  central  incisors  appears  to  depend  upon  defective 
formation  of  the  central  lobe  of  the  tooth.  Fig.  163  (Nos. 
2,  5,  and  6).  Soon  after  eruption  of  the  tooth  this  lobe  wears 
away,  leaving  at  the  centre  of  the  cutting  edge  a  vertical 
notch  (Xo.  1).  If  the  cause  have  acted  so  intensely  as 
entirely  to  prevent  the  development  of  the  central  lobe,  we 
find  instead  of  the  notch  a  narrowing  and  thinning  of  the 
cutting  edge  in  comparison  with  the  crown,  and  this,  accord- 
ing to  its  degree,  produces  a  resemblance  to  a  screwdriver, 
or  to  a  peg  (Nos.  3  and  4).  The  teeth  are  also  usually 
too  small  in  every  dimension,  so  that  the  incisors  are  often 
separated  from  one  another  by  considerable  spaces.  In 
extreme  cases  all  the  incisors  are  peggy  and  much  dwarfed. 
The  changes  are  usually  symmetrical,  but  No.  5  shows  one 
tooth  typically  deformed  and  the  other  normal. 

Fig.  163  (No.  T)  shows  in  an  extreme  degree  the  changes 
due  to  absence  of  enamel  from  the  permanent  teeth  ("mer- 
curial," "stomatitic,"  "strumous,"  and  " rickety"  teeth). 
The  change  occurs  in  lines  running  horizontally  across  the 
whole  set  of  permanent  incisors  and  canines.    When  slight 

20 


458  ETIOLOGY. 

it  aflfects  only  the  part  near  the  edge,  the  enamel  beginning 
as  a  sudden  terrace  or  step  a  little  di^jtance  from  the  edge  ; 

Fig.  163. 


<UO    OCKIKt 


QO     QQ 


OQ      OO 


in  bad  cases  several  such  "terraces"  are  present,  and  the 
whole  tooth  is  rough,  pitted,  and  discolored.     The  first 


ETIOLOGY.  459 

permanent  molars  show  a  corresponding  change  on  the 
grinding  surface.  It  is  this  imperfection  that  is  found 
present  in  nearly  all  cases  of  lamellar  cataract,  though  the 
dental  condition  is  common  enough  in  persons  without  that 
or  any  other  form  of  cataract. 


[SITPPLEME]^T. 

THE    PRACTICAL    EXAMINATION    OF    RAILWAY    EMPLOYEf 

AS    TO   COLOR-BLINDNESS,   ACUTENESS   OF   VISION 

AND  HEARING. 

By  William  Thomson,  M.D. 

In  accordance  with  a  wish  expressed  many  months  ago, 
that  I  should  suggest  some  practical  method  for  the  exami- 
nation of  the  employes  of  the  Pennsylvania  Railroad,  as 
to  their  ability  to  see  the  colored  signals  by  day  and  night 
used  in  the  service,  I  devoted  much  time  to  the  subject,  in 
an  effort  to  overcome  the  following  difficulties : 

1.  To  ascertain  whether  each  man  possesses  sight  enough 
to  see  form  at  the  average  distance ;  and  raiif/e  of  vision  to 
enable  him  to  see  near  objects  well  enough  to  read  written 
or  printed  orders  and  instructions.  2.  To  learn  if  each 
man  has  color-sense  sufficient  to  judge  promptly,  by  day 
or  night,  between  the  colors  in  use  for  signals.  3.  To  de- 
termine the  ability  of  each  man  to  hear  distinctly. 

The  difficulties  to  be  overcome  were  found  in  the  magni- 
tude of  the  task,  involving  the  examination  of  thousands 
of  men  now  in  the  service,  with  the  necessity  of  extending 
it  to  all  who  may  be  hereafter  employed,  distributed  over 
thousands  of  miles  of  road;  and  in  the  absence  of  pro- 
fessional experts  in  sufficient  number,  possessing  enough 
special  training  to  fit  them  to  decide  with  precision  the 
points  at  issue. 

It  soon  became  apparent  that  some  system  would  be 
needed  that  could  be  put  in  force  by  each  division  super- 
intendent, acting  through  an  intelligent  employe,  under 
the  general  supervision  of  one  or  more  ophthalmic  sur- 


462       EXAMINATION    UF    KAIL  WAY    EMPLOYES. 

geons  of  recognized  skill,  to  -whom  all  information  collected 
could  be  transmitted,  and  who  would  be  able  to  decide  all 
doubtful  cases,  and  thus  protect  the  road  from  any  danger 
arising  from  incapable  employes,  and  save  good  and  faith- 
ful men  from  the  evil  of  being  discharged  from  the  com- 
pany's service,  or  prevented  from  being  employed  on  other 
roads  on  insufficient  grounds. 

It  was  believed  that  the  facts  could  be  collected  by  non- 
professional persons,  and  could  be  so  clearly  presented  to 
the  division  superintendent  and  to  the  professional  expert, 
as  to  enable  a  perfectly  correct  decision  to  be  made  in 
every  case ;  and  that  men  fit  for  service  would  be  recog- 
nized, whilst  those  deficient  in  sight,  color-sense,  or  hearing, 
could  be  referred  to  the  expert  if  they  so  desired,  or  trans- 
ferred to  2)laces  in  the  service  where  their  defects,  if  not 
remediable  by  treatment,  could  do  no  harm  either  to  the 
road  or  to  the  public. 

Such  a  system  was  submitted  to  the  general  manager 
of  the  Pennsylvania  Railroad,  and  has  been  perfected 
by  the  labors  of  a  special  committee  of  the  Society  of 
Transportation  Officers  in  conjunction  with  the  writer. 
The  entire  method  has  furthermore  been  submitted  to  a 
practical  experimental  test  extending  over  nearly  two 
thousand  men,  employed  as  conductors,  engineers,  firemen, 
and  brakemen,  and  the  results  have  satisfied  the  committee 
and  myself  that  our  object  has  been  fully  attained,  and 
that  the  system  proposed  may  now  be  put  in  force  with 
confidence  in  its  practical  utility.  As  an  evidence  of  this, 
I  may  cite  two  complete  detailed  reports,  including  1383 
men  in  all.  The  blanks  upon  which  the  original  entries 
were  made  have  all  been  submitted  to  me,  and  they  satisfy 
me  that  the  results  in  the  summary  of  each  of  these  ex- 
cellent reports  may  be  confidently  accepted,  and  thus  we 
have  become  acquainted  with  the  fact  that  there  were  in 
the  service  of  the  Pennsvlvania  Railroad,  of  the  1383  men 


EXAMINATION    OF    RAILWAY    EMPLOYES.       463 

exr.mined,  246  men  deficient  in  the  full  acuteness  of  vision, 
55  absolutely  color-blind,  and  21  defective  in  hearing. 

In  one  of  the  reports,  an  examination,  not  included  in 
the  instructions  from  the  committee,  was  made  with  colored 
flags  and  colored  lights  by  night,  and  13  men  failed  to  be 
able  to  recognize  them  from  a  total  of  24,  who  were  color- 
blind to  the  test  used  for  its  detection,  but  I  have  little 
doubt  whatever  that  the  entire  number  of  color-blind,  viz., 
55,  would  also  fail  under  a  carefully  devised  system  of 
tests  by  the  usual  railroad  signals. 

The  entire  number  reported  as  defective  in  color-sense, 
4^^  per  cent.,  is  up  to  the  average  as  reported  by  the  best 
authorities  in  its  percentage,  but  those  absolutely  color, 
blind,  and  hence  unable  to  distinguish  between  a  soiled 
white  or  gray  and  green,  or  a  green  and  red  flag,  are  fully 
4  per  cent. ;  and  this  proves  that  the  instrument  employed 
in  this  part  of  the  examination  has  met  our  expectations 
fully. 

As  this  was  the  point  about  which  I  had  most  doubt,  a 
word  or  two  of  explanation  may  be  proper,  more  especially 
as  many  good  authorities  declare  that  no  examination  for 
color-blindness  should  be  accepted,  unless  made  by  pro- 
fessional specialists. 

The  examination  for  color-blindness  now  generally  ac- 
cepted and  proposed  by  Prof.  Holmgren,  consists  in  testing 
the  power  of  a  person  to  match  various  colors,  which  are  most 
conveniently  used  in  the  form  of  colored  yarns.  Usually 
about  150  tints  are  employed,  in  a  confused  mixture,  and 
three  test  colors,  viz.,  light-green,  rose  or  purple,  and  red, 
are  placed  in  the  foregoing  order  before  the  person  ex- 
amined, Vv'ho  is  directed  to  select  similar  colors  from  the 
mass.  The  examiner  sits  then  in  judgment,  and  decides 
whether  the  color-sense  is  perfect  from  the  selections  made, 
or  from  those  not  made,  or  from  them  both,  and  from  the 
prompt  or  hesitating  manner  of  the  examined.     It  has 


4f>4       KX  A  MI  NATION    OF    RAILWAY    EMPLOYES. 

been  our  effort  to  render  this  more  simple,  and  to  so  ar- 
range tbe  colors  that  they  may  be  identified  by  some  num- 
ber, so  that  an  expert,  although  absent  from  the  scene, 
%vould  know  by  these  numbers  the  exact  tints  selected,  and 
thus  be  fully  competent  to  declare  from  them  the  color- 
perception  of  any  person  whose  record  had  been  properly 
made.  From  theory  based  upcm  scientific  knowledge,  and 
from  much  experience,  I  was  able  to  arrange  an  instru- 
ment that  would  have  the  real  colors,  and  those  usually 
confounded  with  them,  "  confusion  colors,"  placed  in  such 
relations  to  each  other,  and  so  designated  by  numbers,  as  to 
make  an  examination  for  color-blindness  possible  by  a  non- 
professional person,  who  could  conduct  the  testing,  record 
it  properly,  and  transmit  it  to  an  expert  capable  of  decid- 
ing upon  the  written  results.  Hence  there  is  no  departure 
from,  the  system  of  matching  tints  already  established,  the 
only  novelty  being  in  reducing  the  number  of  colors  to 
those  similar  to  the  test  colors,  and  to  those  usually  chosen 
by  C(.>lor-blind  persons,  and  so  identifying  them  as  to  enable 
an  absent  expert  or  superintendent  to  know  precisely  what 
colors  had  been  selected  to  match  the  test  colors. 

The  theory  of  the  instrument  (consisting  of  a  stick  with 
the  yarns  attached,  see  Fig.  164),  is  that  color-blindness  is 
most  promptly  detected  by  using  the  light-green  test-skein^ 
and  asking  that  it  be  matched  in  color  from  the  yarns  on 
the  stick,  which  are  arranged  to  be  alternately  green  and 
confusion  colors,  and  are  numbered  from  one  to  twenty,  the 
person  being  directed  to  select  ten  tints,  and  the  examiner 
being  required  to  note  the  numbers  of  the  tints  chosen.  It 
will  be  understood  that  the  odd  numbers  are  the  green,  and 
the  even  ones  the  confusion  colors,  and  that,  if  a  person  has 
a  good  color-sense,  his  record  will  exhibit  none  but  odd  num- 
bers; whilst,  if  he  be  color-blind,  the  mingling  of  even  num- 
bers betrays  his  defect  at  a  glance  to  the  supervising  expert 
or  superintendent. 


EXAMINATION    OF    RAILWAY    EMPLOYES.       465 


46G       EXAMINATION    OF    RAILWAY    EMPLOYES. 

There  are  forty  tints  on  the  stick,  and  the  first  twenty 
are  given  to  the  detection  of  color-blindness,  using  the 
grcen-tcst,  and  if  the  color-sense  is  deficient,  it  will  surely 
be  revealed. 

To  distinguish,  however,  between  green-blindness  and 
red-blindness,  the  rose-test  is  used,  and  those  color-blind  will 
select  indifferently,  either  the  blues  intermingled  with  the 
rose,  between  figures  20  and  30,  or  perhaps  the  blue-green 
or  grays  from  1  to  20,  and  thus  reveal  their  defect,  and  es- 
tablish either  green-  or  red-blindness. 

Finally,  the  red-test  corroborates  these  results,  and  satis- 
fies the  most  sceptical  of  color  defect,  when  the  "  confusion 
tints  "  or  even  numbers  between  30  and  40  are  selected. 

On  a  suitable  blank  these  figures  are  placed  in  the  order 
of  examination,  and  a  glance  of  the  eye  reveals  the  color- 
sense  of  the  person  examined;  since,  if  anything  but  odd 
numbers  are  chosen,  there  is  a  defect ;  or  if,  with  test  one, 
anything  beyond  20  is  chosen ;  or  if,  with  test  two.  any- 
thing but  odd  numbers  between  20  and  30 ;  or,  wit'i  test 
three,  anything  but  odd  numbers  between  30  and  40.  The 
colors  can  readily  be  changed  on  the  instrument,  if  it  should 
be  found  desirable. 

It  is  theoretically  and  practically  a  fact,  that  the  tints  as 
arranged  in  the  three  sets  on  the  instrument  look  C|uite  the 
same  in  color  to  color-blind  persons,  and  that  those  having 
a  perfect  color-sense  can  thus  form  an  idea  of  this  infirmity. 
If,  then,  green  and  gray  are  indistinguishable,  and  green  and 
red,  when  of  the  same  depth  of  color,  seem  to  be  entirely  the 
same  to  the  color-blind,  it  needs  no  opinion  from  a  scien- 
tific expert  to  convince  the  manager  of  a  railroad  that  it 
would  be  most  dangerous  to  place  the  lives  of  people  under 
the  guidance  of  an  engineer  who  could  not  distinguish,  if 
green-blind,  between  a  soiled  white  and  a  green  flag,  or  be- 
tween a  green  and  red  flag,  or  other  signal  of  these  colors. 

It  is  a  fact  that  some  of  the  color-blind  promptly  give 


EXAMINATION    OF    RAILWAY    EMPLOYES.       467 

the  proper  names  to  the  flags,  and  answer  correctly,  when 
asked  what  they  would  do  in  presence  of  such  signals,  but 
it  must  be  remembered  that  they  may  see  form  perfectly, 
and  have  always  had  some  perception  of  these  colors,  and  do 
give  them  their  conventional  names,  perhaps,  but  that  they 
are  unable  to  distinguish  them  at  once  and  infallibly,  and 
that  it  will  only  require  a  further  extension  of  our  method 
of  testing  to  demonstrate  the  inability  of  persons  color- 
blind to  our  examination  to  recognize  the  signals,  by  day 
or  night,  which  are  now  depended  upon  to  prevent  acci- 
dents of  the  gravest  character.  This  must  be  done  by  de- 
manding that  the  signals  be  matched,  and  not  named,  and 
this  is  incorporated  in  the  instructions  herewith  submitted, 
so  that  the  tints  which  color-blind  men  select  with  the  rail- 
road signals  from  the  instrument  may  hereafter  be  known 
and  recorded. 

My  conclusions  from  a  study  of  the  subject  in  connection 
with  the  railway  service  are : 

1.  That  there  are  many  employes  who  have  defective 
sight,  caused  either  by  optical  defects,  which  are,  perhaps, 
congenital,  and  which  might  be  corrected  with  proper 
glasses,  or  due  to  the  results  of  injuries  or  diseases  of  the 
eyes,  remediable  or  not,  by  medical  or  surgical  treatment. 

2.  That  one  man  in  twenty-five  will  be  found  color-blind 
to  a  degree  to  render  him  unfit  for  service  where  prompt 
recognition  of  signals  is  needed,  inasmuch  as  color-blmdness 
for  red  and  green  renders  signals  of  these  colors  indistin- 
guishable. It  is  a  fact  in  physiological  optics,  however, 
that  yellow  and  blue  are  seen  by  those  color-blind  for  red 
and  green,  and  that  yellow-violet  blindness  is  so  rare  that 
it  might  lead  to  the  use  of  these  yellow  and  blue  colors,  in 
preference  to  red  and  green,  wherever  possible. 

3.  That  color-blindness,  although  mainly  congenital  and 
incurable,  is  sometimes  caused  by  disease  or  injury,  and 
that  precautions  might  be  needed  to  have  either  periodical 


468        KXAMliNATloN     (j  F    RAILWAY    EMPLOYES. 

examinations  or  to  insist  upon  it  in  cases  where  men  have 
siiftered  from  severe  illness  or  injury,  or  when  they  have 
been  addicted  to  the  abuse  of  tobacco  or  alcohol. 

4.  That  the  method,  when  adopted,  will  enable  the 
authorities  to  know  exactly  how  many  of  their  employes 
are  "satisfactory  in  every  particular"  as  to  sight  and  hear- 
ing; and  that  the  examination  will  have  the  further  value 
of  making  the  division  superintendents  acquainted  with 
the  general  aptitude  of  the  men  in  their  divisions  as  to  gen- 
eral intelligence. 

5.  That  the  entire  examinations  can  be  made  at  the  rate 
of  at  least  six  men  an  hour;  whilst  that  for  color-sense 
alone  can  be  done  in  a  very  few  minutes  for  each  man  by 
an  intelligent  employe. 

6.  That  to  secure  the  confidence  of  the  employes,  and  of 
competent  scientific  critics,  as  well  as  of  the  public  gener- 
ally, it  is  advisable  to  have  some  oflScial  professional 
specialist  to  whom  all  doubtful  questions  could  be  referred, 
and  who  should  be  held  responsible  for  the  accuracy  of  the 
instruments,  test-cards,  etc.,  to  be  put  in  use,  and  who  should 
have  a  general  supervision  of  the  entire  subject  of  sight, 
color-sense,  and  hearing. 

7.  That  from  the  impossibility  of  subjecting  the  immense 
number  of  employes  on  our  large  railways  to  the  inspection 
of  the  few  medical  experts  available,  and  to  secure  the  ex- 
amination of  those  hereafter  to  be  employed,  some  eystem 
of  testing  by  the  railway  superintendents  has  become  a 
necessity,  and  it  is  believed  that  the  one  proposed  will  an- 
swer the  purpose. 


EXAMINATION    OF    RAILWAY    EMPLOYES.       469 


Pennsylvania  Railroad  Co:.ipany's  Instructions  for 
Examination  of  Employes  as  to  Vision,  Color- 
blindness, and  Hearing. 

Instructions  for  examination  as  to  vision,  color-blind- 
ness, and  hearing^. — The  examination  will  be  made  as  to 
vision,  color-sense,  and  hearing,  and  the  following  appa- 
ratus will  be  used : 

1.  A  card  or  disk  of  large  letters  for  testing  distant 
sight.  2.  A  book  or  card  of  print  for  testing  sight  at  a 
short  distance.  3.  An  adjustable  frame  for  supporting  the 
print  to  be  read,  with  a  graduated  rod  attached  for  meas- 
uring the  distance  from  the  eye  while  reading.  4.  A  spec- 
tacle frame  for  obstructing  the  vision  of  either  eye  while 
testing  the  other.  5.  An  assortment  of  colored  yarns  for 
testing  the  sense  of  color.  6.  A  watch  with  a  loud  tick  for 
testing  the  hearing.  7.  A  book  or  set  of  blanks  for  record- 
ing the  observations.  8.  A  copy  of  an  approved  work  on 
"  Color-blindness." 

Acnteness  of  vision. — For  distant  vision,  place  the  test- 
disk  or  card  in  a  good  light  twenty  feet  distant,  and  ascer- 
tain for  each  eye  separately  the  smallest  letters  that  can 
be  read  distinctly,  and  record  the  same  by  the  number  of 
that  series  on  the  card. 

Range  of  vision. — For  near  vision,  ascertain  the  least 
number  of  inches  at  which  type  D  =  0.5  or  H,  can  be  read 
with  each  eye,  and  record  the  result. 

Field  of  vision. — Let  the  examiner  stand  in  front  of  the 
examined,  at  a  distance  of  three  feet,  and  directing  the  ex- 
amined to  fix  his  eyes  on  the  right  eye  of  the  examiner,  and 
keep  them  so  fixed,  let  the  examiner  extend  his  arm  later- 
ally, and  opening  and  shutting  his  hands,  let  him  by  ques- 
tions satisfy  himself  that  his  hands  are  seen  by  the  examined 


470       EXAMINATION    OF    RAILWAY   EMPLOYES. 

without  changing  the  direction  of  the  eyes ;  recording  the 
result  as  good  or  defective,  as  the  case  may  be. 

Color-sense. — Three  tcst-skeins — A,  light-green;  B,  rose; 
C,  red — will  be  used  with  the  colored  yarns  attached  to 
the  stick ;  of  the  latter  there  are  forty  tints,  numbered  from 
1.  to  40,  and  arranged  in  three  sets — a,  b,  and  c — of  which 
the  odd  numbers  correspond  to  the  colors  of  the  test-skeins, 
whilst  the  even  numbers  are  different  or  "  confusion  colors." 

The  first  set  is  to  test  for  color-blindness;  the  second  to 
determine  whether  it  be  red  or  green  blindness,  and  the 
third  to  confirm  the  opinion  formed  from  the  first  or  second 
test. 

Place  the  test-skein  A  at  a  distance  of  not  less  than  three 
feet,  and,  without  naming  the  color,  direct  the  person  ex- 
amined to  name  the  color,  and  to  select  from  the  first 
twenty  tints,  or  set  (a),  of  the  yarns  on  the  stick,  ten  tints 
of  the  same  color  as  skein  A,  stating  that  they  do  not 
match,  but  are  different  shades  of  the  same  color.  Record 
the  number  of  the  tints  so  selected.  Do  the  same  with  skeins 
B  and  C,  using  for  B  the  tints  from  21  to  30,  and  for  C  the 
tints  from  31  to  40.  If  the  odd  numbers  are  selected  read- 
ily, the  examination  may  be  gone  over  very  quickly. 

When  color-blindness  is  detected,  any  one  of  the  even 
numbers  or  "  confusion  colors  "  may  be  used  as  a  test-skein, 
and  the  man  may  be  directed  to  select  similar  tints,  when 
he  will  most  probably  choose  odd  numbers,  which  should 
be  recorded,  stating  the  number  on  the  stick  of  the  "  con- 
fusion color"  used  for  a  test,  and  then  giving  the  numbers 
chosen  to  match  it. 

Then  a  soiled  ivhite  flag  should  be  shown,  and  the  man 
be  directed  to  select  tints  to  match  it,  which  should  be  re- 
corded ;  next  a  green,  and  finally  a  red  flag. 

All  of  the  particulars  are  to  be  recorded  as  the  examina- 
tion proceeds,  not  leaving  it  to  memory.  Use  the  numbers 
in  recording.     The  letters  indicating  the  set  need  not  be 


EXAMINATION    OF    RAILWAY    EMPLOYES.       471 

used.  ^N'ote  whether  the  selection  is  prompt  or  hesitating 
by  a  distinct  mark  after  the  proper  word  en  the  blank 
form.  When  deficient  color-sense  is  discovered,  and  varia- 
tions in  the  mode  of  testing  arc  made  by  the  examiner  or 
examined,  they  should  be  noted  under  remarks,  or  on  a 
separate  sheet  to  be  referred  to,  if  the  blank  has  not  room 
enough. 

Hearing. — Note  the  number  of  feet  or  inches  distant 
from  each  ear  at  which  a  watch,  having  a  tick  loud 
enough  to  be  heard  at  five  feet,  is  heard  distinctly,  using  a 
watch  without  a  tick,  or  a  stop  watch,  to  detect  any 
supposed  deception;  and  the  number  of  feet  at  which 
ordinary  conversation  is  heard. 

Explanations. — The  test-card  contains  letters,  numbered 
from  20  (xx),  or  D  =  6,  to  200  (cc),  or  D  =  GO.  Those 
measuring  three-eighths  of  an  inch,  and  numbered  20  (xx) 
or  D  =  6,  are  such  as  a  good  eye  of  ordinary  power  sees  dis- 
tinctly twenty  feet  or  six  metres  distant.  If  a  man  sees 
distinctly  only  those  marked  C  (or  100),  his  acuteness  of 
vision,  v.,  is  equal  to  -f-^^  or  ^.  If  he  sees  to  XX  (or  20), 
then  Y.  is  equal  to  ||-  or  1,  and  his  sight  is  up  to  the  full 
standard.  This  mode  of  statement  indicates  the  relative 
value  of  the  sight  examined,  and  should  be  used  in  the 
records.  If  one  eye  is  |^  or  1,  and  the  other  not  less  than 
f^  or  -Ij^,  with  or  without  glasses,  the  sight  may  be  con- 
sidered satisfactory. 

The  power  of  discerning  small  objects  at  the  reading 
distance  is  tested  by  the  small  j^rint,  and  good  sight  may 
be  assumed  if  one  eye  can  see  at  twenty  inches  the  matter 
marked  l*  or  D  =  0.o,  whilst  the  other  distinguishes  not 
less  than  4}  or  D=  1.5.  The  small  print  should  then  be 
brought  to  the  j^oint  of  nearest  vision  for  each  eye,  and  that 
point  mentioned  in  inches.  A  good  eye  should  be  able  to 
read  Xo.  1  ^  at  twenty  inches,  and  have  a  range  of  vision 
up  to  ten  inches. 


472       KXAMINATION    OF    K  A  I  J>  W  A  Y    EMPLOYES. 

The  color-test  will  indicate  ^vliether  tlic  man  is  deficient 
in  color  sense.  The  colors  arc  arranged  in  three  sets,  one 
of  20  and  two  of  10  each — the  odd  numbers  arc  the  colors 
similar  to  the  test-skeins,  and  the  even  numbers  are  the 
"  confusion  colors,"  or  those  which  the  color-blind  will  be 
likely  to  select  to  match  the  sample  skeins  or  colors  shown 
him.  The  first  20  (a),  numbered  from  1  to  20,  have  green 
tints  for  the  odd  numbers  or  test-colors.  In  the  second 
(6),  21  to  30,  the  test-colors  are  rose  or  purple,  a  combina- 
tion of  red  and  blue ;  and  in  the  third  (c),  31  to  40,  they  are 
red.  Ordinarily  the  test  will  be  with  each  set  separately, 
but  the  whole  40  may  be  employed  on  any  test-skein.  Any- 
thing but  green  matched  with  r/reen  indicates  a  defect  in 
the  color  sense,  for  which  use  set  (a). 

The  test  with  the  second  set  indicates  whether  red  or 
green  blindness  exists.  The  odd  numbers  from  21  to  30 
are  purple.  If  either  of  these  is  matched  with  test-skein 
B,  nothing  is  indicated,  as  they  must  appear  alike  to  a 
color-blind  person ;  but  if  blue  is  chosen,  red-blindness  is 
indicated,  and  if  green,  then  green-blindness  is  established. 

The  third  set  (c)  is  scarcely  needed,  but  may  be  used  in 
confirmation  of,  or  in  connection  with,  the  last,  as  to  red  or 
green  defect. 

\Yhen  the  numbers  of  the  tints  selected  are  recorded  in 
the  proper  blank,  color-blindness  will  be  indicated  in  those 
instances  where  even  numbers  appear,  and  suspicions  will 
arise  where  numbers  beyond  20  are  used  with  test-skein  A, 
and  under  21  or  beyond  30  with  B,  and  below  31  with  C. 

Further  tests  should  be  made  of  those  found  to  be  color- 
blind with  the  usual  signal  flags,  requesting  them  to  name 
each  color,  shown  singly,  and  to  match  the  colors  cf  them 
from  the  tints  on  the  stick,  and  with  colored  lamps ;  and 
finally  to  state  what  they  understand  them  to  mean  as 
signals. 

It  will  be  well  not  to  dwell  on  the  examination  of  a  man 


EXAMINATION    OF    RAILWAY    EMPLOYES.       473 

found  to  be  defective  in  color-sense  or  in  vision,  but  t;)  pass 
over  each  examination  with  the  same  general  care,  and 
afterwards  send  for  those  giving  indications  of  defects,  to 
come  in  singly  for  fuller  examination.  The  examination 
should  be  private  as  far  as  practicable,  especially  excluding 
persons  who  are  to  be  subsequently  examined. 

Inability  to  name  color  accurately,  or  to  distinguish 
nicely  as  to  difference  in  tint,  is  not  to  be  taken  as  an  evi- 
dence of  color-blindness. 

In  testing  as  to  hearing,  if  the  watch  used  can  be  heard 
at  five  feet  distant,  and  the  person  examined  hears  it  only 
at  one  foot,  his  hearing  would  be  1-5,  and  may  be  so 
recorded  in  fractions.  Conversation  in  an  ordinary  tone 
should  be  heard  at  ten  feet. 

It  should  be  understood  that  all  employes  examined, 
failing  to  come  up  to  the  requirements  of  the  above  stand- 
ard, shall  be  accorded  the  benefit  of  a  professional  ex- 
amination. When  acuteness  of  vision  is  below  the  standard 
adopted,  it  may  be  possible  to  restore  full  vision  by  proper 
glasses,  when  it  is  due  to  optical  defects,  known  as  near- 
sight,  far-sight,  or  astigmatism,  or  by  other  medical  or 
surgical  treatment,  and  useful  men  may  then  be  retained 
in  the  company's  service. 

These  rules  and  regulations,  having  been  approved  by 
the  Board  of  Managers,  have  been  put  into  effect  en  the 
Pennsylvania  Railroad,  under  the  general  supervision  of 
the  writer,  and  give  entire  satisfaction.] 


APPENDIX. 


FORMIJLJE,  ETC. 

Nitrate  of  Silver. 

1.  Mitigated  Solid  Nitrate  of  Silver  (B.  P.  1885): 

Nitrate  of  Silver  1, 
Nitrate  of  Potash  2. 

Fused  together  and  run  into  moulds  to  form  short,  pointed 
sticks. 

Used  for  granular  lids  and  purulent  ophthalmia. 

The  strength  above  given  is  known  as  No.  1,  and  is  that  which 
I  generally  use  ;  three  weaker  forms  are  made,  known  as  Nos.  2, 
3,  and  4,  containing  respectively  3,  3^,  and  4  parts  of  nitrate  of 
potash  to  1  of  nitrate  of  silver. 

Pure  nitrate  of  silver  is  never  to  be  used  to  the  conjunctiva. 

2.  Solutions  of  Nitrate  of  Silver  : 

(1)  Nitrate  of  Silver  gr.  x  or  xx. 
Distilled  Water  gj. 

Used  by  the  surgeon  for  purulent  ophthalmia,  granular  lids, 
and  chronic  conjunctivitis,  and  some  cases  of  ulcer  of  the  cornea. 

3.  (2)  Nitrate  of  Silver  gr.  j  or  ij, 

Distilled  Water  gj. 

Used  by  the  patient  in  various  forms  of  ophthalmia  ;  only  a  few 
drops  to  be  used  at  a  time,  and  not  more  than  three  times  a  day. 

All  solutions  of  nitrate  of  silver  should  be  kept  in  glass-stop- 
pered bottles  ;  any  trace  of  organic  matter  decomposes  the  salt, 
and  a  black  deposit  of  metallic  silver  falls  to  the  bottom  ;  the 
action  of  light  favors  this  decomposition  :  amber-tinted  glass  is 
said  to  counteract  the  chemical  action  of  light.  Dark-blue  bottles 
should  not  be  used,  as  they  only  hide  the  deposit  of  reduced  silver. 


476  APPENDIX. 

Sulphate  of  Copper. 

4.  A  crystal  of  Pure  Sulphate  of  Copper,  smoothly  pointed, 
may  be  used  for  touching  granular  lids  of  old  standing. 

5.  Lapis  Divinus  : 

Sulphate  of  Copper  1, 

Alum  1, 

Nitrate  of  Potash  1. 

Fused  together,  and  camphor  equal  to  3^5  of  the  whole  added. 
The  preparation  is  run  into  moulds  to  form  sticks.  It  should  be 
kept  in  a  stoppered  bottle. 

Largely  used  for  the  treatment  of  chronic  granular  lids. 

6.  Solutions  of  sulphate  of  copper  or  of  Lapis  Divinus,  gr.  j 
in  §j  of  distilled  water,  are  also  very  useful  for  many  forms  of 
chronic  conjunctivitis. 

Lead  Lotion  : 

7.  Liquor  Plumbi  Subacetatis  (B.  P.)  5j. 
Distilled  Water  Oj. 

(1  in  100.) 

Used  in  chronic  conjunctivitis  vhen  the  cornea  is  sound,  and  in 
inflammation  of  the  eyelids  and  lachrymal  sac. 

Spirit  Lotion  : 

8.  Rectified  (or  Methylated)  Spirit  giv, 
Water  §xvj. 

Used  as  an  evaporating  lotion  to  allay  or  prevent  inflammation 
of  the  wound  after  operation  on  the  eyelids. 

9.  Lead  and  Sjnrit  Lotion  : 

Spirit  Lotion  Oj, 

Liquor  Plumbi  Subacetatis  (B.  P.)  '^\], 

Used  in  the  same  cases  when  there  is  no  fear  that  the  cornea  is 
abraded  or  ulcerated.     A  better  antiphlogistic  than  spirit  alone. 

Mercury  : 

10.  Since  the  publication  of  Sattler's  experiments  on  anti- 
septics in  18S3,  weak  Solutions  of  Perchloride  of  Mercury  have 
come  largely  into  use  for  cleansing  the  conjunctiva,  eyelids,  etc., 


APPENDIX.  477 

before,  during,  and  after  operations,  this  salt  being,  according  to 
that  author,  the  best  available  germicide.  A  solution  of  1  grain 
in  5000  of  water  (common  or  distilled)  (=  gr.  j  in  fl.  ^xij)  may 
be  freely  used  for  the  above  purposes,  and  a  stronger  one  (1  to 
2500)  (=gr.  j  in  fl.  gvj)  as  a  lotion  for  catarrhal  ophthalmia,  etc. 
Some  surgeons  use  much  stronger  solutions. 

The  Moorfields  Pharmacopoeia  has  a  lotion  containing  1  grain  in 
fl.  gviij,  orlin  3500. 

The  officinal  solution  (liq.  hydrarg.  perchlor.)  contains  chloride 
of  ammonium  also,  and  is  decomposed  and  rendered  almost  inert 
if  diluted  with  common,  instead  of  distilled,  water  ;  but  a  solution 
of  perchloride  alone  in  common  or  distilled  water  is  stable.  (Mar- 
tindale's  Extra  Pharmacopoeia.) 

11.  Calomel  Poivder : 

Used  for  dusting  on  the  cornea  in  some  cases  of  ulceration.  It 
is  flicked  into  the  eye  from  a  dry  camel-hair  brush. 

12.  Yellow   Oxide   of  Mercury  {^^  Yellow    Ointment,^ ^    ^' Pagen- 

stecher^s  OintmenV)  : 

Yellow  Oxide  of  Mercury  gr.  xxiv, 
Vaseline  §j. 

(1  in  20.) 

13.  "Weaker  preparations,  containing  gr.  viij   or  less  of  the 
yellow  oxide  to  ,^j  (1  in  60  or  less),  are  often  better  borne. 

Used  in  many  cases  of  corneal  ulceration  and  recent  corneal 
nebulae ;  a  morsel  as  large  as  a  hemp-seed  being  inserted  within 
the  lower  lid,  by  means  of  a  small  brush,  once  or  twice  a  day.  It 
is  also  suitable  for  ophthalmia  tarsi. 

In  some  of  the  continental  eye  hospitals,  where  it  is  the  custom 
for  this  remedy,  amongst  others,  to  be  applied  by  the  surgeon  him- 
self, stronger  preparations  are  used. 

14.  Yellow  Ointment  with  Atropine : 

Yellow  Oxide  of  Mercury  gr.  viij  or  less, 
Atropine  gr.  \, 
Vaseline  5J- 

Used  in  the  same  way  as  12  and  13. 

15.  Red  Oxide  of  Mercury : 

Red  Oxide  of  Mercury  gr.  xxiv  or  less, 
Vaseline  51. 


478  APPENDIX. 

Used  for  ophthalmia  tarsi,  etc.  Was  formerly  used  for  corneal 
ulcers  and  nebulae;  but  the  yellow  oxide,  which  being  made  by 
precipitation  is  not  crystalline,  is  now  generally  preferred  because 
less  irritating.! 

16.  Nitrate  of  Mercury  {Citrine  Ointment'): 

Unguentum  Hydrargyri  Nitratis  (B.  P.)  3j> 
Vaseline  or  Prepared  Lard  S'^ij* 

Used  in  the  same  cases  as  15. 

17.  Iodoform : 

Iodoform  may  be  used  either  in  substance  or  as  an  ointment 
made  with  vaseline. 

Iodoform  gr.  x  to  xxx  or  more, 

Vaseline  §j. 

Ung.  lodoformi  (B.  P.  1885)  : 

Iodoform  gr.  xlviij, 
Benzoated  Lard  §j. 

18.  lodol,  which  is  odorless,  may  be  used  in  the  same  way. 
The  precipitated  iodoform  (impalpable  powder)  should  be  used  in 
preference  to  the  ordinary,  or  crystalline,  form,  for  the  eye. 

Sulphate  of  Zinc  : 

19.  Sulphate  of  Zinc  gr.  j  or  ij, 
Water  or  Rose  Water  3J« 

Chlobide  of  Zinc  : 

20.  Chloride  of  Zinc  gr.  ij, 
Water  gj. 

If  there  is  a  deposit,  add  of  dilute  hydrochloric 
acid  just  enough  to  make  a  clear  solution. 


1  The  ointment  known  as  "  Singleton's  Golden  Eye  Ointment"  ap- 
pears to  contain  a  crystalline  red  oxide  in  fine  powder  as  its  active 
ingredient.  A  sample,  kindly  analyzed  for  me  by  Mr.  S.  Plowman, 
contained  70  grains  of  the  oxide  to  the  ounce. 


APPENDIX.  479 

21.    Chloride  of  Zinc  Paste  (  Caustic) : 

(i;^  Chloride  of  Zinc  1, 
Wheat  Hour  2,  3,  o:  4. 

Water  enough  to  make  a  thick  paste.  (St.  Thomas's 
Hospital.) 

(2)  Allow  solid  Chloride  of  Zinc  to  deliquesce,  add  a 

little  glycerine,  and  make  into  a  paste  with 
powdered  Sanguinaria.  The  glycerine  prevents 
hardening  on  keeping.     (St.  Thomas's  Hospital.) 

(3)  Chloride  of  Zinc  480  grains  (8), 
Wheat  flour  ISO  grains  (3), 

Water  or  Liquor  Opii  Sedativus,  fl.  §j  (8).  (Middle- 
sex and  Moorfields  Ophthalmic  Hospitals.) 

(4)  Chloride  of  Zinc  1, 
Freshly-burned  Plaster-of-Paris  2. 

Made  into  a  paste  with  a  few  drops  of  water. 
(Druitt's  "  Vade  Mecum,"  9th  ed.j 

(5)  Chloride  of  Zinc  1, 
Oxide  of  Zinc  1, 
Wheat  flour  2. 

Water  enough  to  make  a  stiflf  paste,  which  is  made 
into  caustic  points.     (Squire,  13th  ed.) 

It  would  seem  from  the  above  that  the  exact  composition  of  the 
paste  is  not  of  much  importance.  It  would  be  desirable  to  have 
the  point  settled. 

Alum: 

22.  A  stick  of  pure  crystalline  alum  forms  a  very  useful  ap- 
plication for  mild  or  long-standing  cases  of  granular  conjunctiva, 
and  for  many  forms  of  chronic  palpebral  conjunctivitis.  It  may 
be  used  by  the  patient  himself  without  the  slightest  risk. 


23.  Lotion-. 

Alum  gr.  iv  to  gr.  x, 
Water  gj* 


The  above  lotions  are  in  common  use  in  the  milder  forms  of  acute 
and  chronic  ophthalmia.  The  chloride  of  zinc  occasionally  irri- 
tates ;  it  is  specially  used  in  purulent  and  severe  catarrhal  oph- 


480  APPENDIX. 

thalmia  instead  of  the  weak  nitrate  of  silver  lotions.  The  stronger 
alum  lotion  is  often  used  in  the  same  cases.  The  alum  and  sul- 
phate of  zinc  lotions  may  be  used  unsparingly  to  the  conjunctiva  ; 
the  chloride,  even  in  severe  cases,  not  more  than  six  times  a  day. 

Carbonate  of  Soda : 

24.  Carbonate  of  Soda  gr.  x, 

Water  gj. 

Used  for  softening  the  crusts  in  severe  ophthalmia  tarsi.  A 
small  quantity  of  the  lotion,  diluted  with  its  own  bulk  of  hot 
water,  to  be  used  for  soaking  the  edges  of  the  eyelids  for  ten  or 
fifteen  minutes  night  and  morning. 

Tar  and  Soda  : 

25.  Carbonate  of  Soda  3J=5S, 

Liquor  Carbonis  Detergens  3J  to  5^^> 
Water  to  Oj. 

Used  in  the  same  cases  as  the  last. 

Borax  : 

2tj.  Biborate  of  Soda  gr.  x  to  xx, 

Water  §j . 

Used  in  the  same  cases  as  the  last. 

Quinine  Lotion  : 

27.  Sulphate  of  Quinine  gr.   iij, 

Acid.  Sulph.  dil.  (B.  P.)  just  enough  to  dissolve, 
Water  gj. 
Used  in  diphtheritic  ophthalmia. 

Boric  Acid  Lotion  : 

28.  Boric  Acid  4, 
Water  100  by  weight. 

Used  as  an  antiseptic  before  and  after  operations  on  the  eyeball, 
and  in  the  treatment  of  suppurating  ulcers  of  the  cornea. 

Boric  acid  in  very  fine  powder  may  be  used  for  dusting  on  to 
the  cornea  in  cases  of  severe  suppurating  ulcer  ;  it  causes  scarcely 
any  paiu  and  may  be  applied  as  often  as  three  times  a  day.  The 
crystals  are  difficult  to  powder  finely,  but  an  almost  impalpable 
amorphous  powder,  obtained  by  preventing  regular  crystallization, 
can  be  had. 


APPENDIX.  481 

Mr.  Martindale  has  made  for  me  some  soluble  styles  contaiuing 
about  60  per  cent,  of  boric  acid,  for  use  in  cases  of  lachrymal  ob- 
struction with  much  secretion  of  mucus. 

Solutions  of  boric  acid  often  tarnish  steel ;  instruments  should 
therefore  not  be  left  in  them. 

Boric  Acid  Oixtmext  (B.  P.  1885)  : 

Boric  Acid  gr.  Ixviij  to  gj  of  Paraffin. 
Carbolic  Acid   Lotiox  : 

29.  Aiisolute  Phenol  5, 
Water  by  weight  100. 

Used  in  purulent  ophthalmia.  It  is  important  to  use  absolutely 
pure  carbolic  acid  for  the  conjunctiva.  Severe  irritation  often 
follows  if  any  other  varieties  are  employed. 

Lotion  of  snlicylic  acid  is  so  irritating  to  the  surface  of  the  eye 
that  it  can  seldom  be  used.  The  same  objection  applies  to  salicylic 
wool  used  for  dressing  the  eye  after  operations . 

30.  Cocaine. 

Cocaine  was  brought  into  clinical  use  in  September,  1884,  at 
Vienna,  and  in  Loiidon  and  elsewhere  early  in  October. 

A  two  per  cent,  solution  of  a  salt  of  cocaine  dropped  into  the  con- 
junctival sac  causes  smarting  for  about  half  a  minute,  followed  by 
numbness,  rising  to  complete  anaesthesia  of  ocular  conjunctiva  and 
cornea  in  about  two  to  five  minutes  ;  in  three  to  five  minutes  after 
the  maximum  is  reached,  feeling  begins  to  return,  but  slight 
numbness  continues  for  about  twenty  minutes.  There  is  often  a 
feeling  of  coldness  as  sensation  is  returning.  Coacine  also  causes 
widening  of  the  palpebral  fissure  by  retraction  of  the  upper  and 
lower  lids,  whitening  of  eyeball  from  contraction  of  bloodvessels, 
mydriasis,  very  slight  weakness  of  Ace,  and  perhaps  lowering  of 
the  eye  tension.  These  efi"ects  last  about  half  an  hour,  except  the 
myd.riasis,  which  remains  in  some  degree  about  twenty-four  hours. 
The  pupil  dilated  by  cocaine  remains  active  to  light  and  Ace.  ;  if 
atropine  be  added  the  pupil  becomes  larger  than  from  either  drug 
singly.  Eserine  quickly  and  fully  overcomes  the  etfect  of  cocaine. 
Ace.  is  completely  paralyzed  for  a  short  time  if  cocaine  be  used 
every  few  minutes  for  about  an  hour.  These  eflfects  of  cocaine 
(except  the  last)  are  explicable  on  the  supposition  that  it  causes 
spasm  of  the  sympathetic    nerve- fibres    to  the    eyelids,   iris,  and 

21 


482  APPENDIX. 

superficial  bloodvessels ;  whether  a  similar  contraction  of  the 
arteries  of  the  ciliary  muscle,  brought  about  by  the  repeated  use 
of  the  drug,  explains  the  fleeting  paralysis  of  Ace.  is  open  to 
question.  Cocaine  has  no  ascertainable  action  on  the  vessels  of  the 
retina  and  choroid.  Cocaine  is  thought  by  some  to  aid  the  action 
of  eserine  in  chronic  glaucoma,  when  the  two  are  used  together  ; 
this  is  intelligible  if  cocaine  acts  by  contracting  the  ciliary  arteries. 
In  ophthalmology  cocaine  is  used  chiefly  for  anaesthfsia  before 
operations  on  the  eyeball,  and  painful  applications  to  the  palpe- 
bral conjunctiva.  For  the  former,  a  freshly  made  two  per  cent, 
solution  of  perfectly  pure  hydrochlorate  of  cocaine  in  freshly 
boiled  distilled  water  is  the  safest  preparation  ;  but  gelatine  discs 
of  the  pure  Fait,  if  free  from  hygroscopic  tendency,  may  be  safely 
used.  Solutions  in  oil  or  vaseline  are  uncleanly  and  not  suitable 
for  surgical  purposes.  Watery  solutions  of  cocaine  should  be  used 
quite  fresh  ;  even  if  made  with  boracic  acid  or  camphor  water, 
they  often,  if  kept,  grow  fungi,  and  are  then  unsafe.  Bichloride 
of  mercury  in  suflBcient  quantity  to  prevent  growth,  sometimes, 
in  conjunction  with  cocaine,  causes  considerable  haziness  of  the 
cornea.  Even  cocaine  alone,  if  too  freely  used,  causes  dryness, 
loosening,  and  even  separation  of  the  corneal  epithelium :  the 
desiccation  of  the  corneal  epithelium  is  said  to  occur  in  direct  pro- 
portion to  the  frequency  of  use  of  the  cocaine  and  of  exposure  of 
the  cornea  to  the  air,  rather  than  to  the  strength  of  the  solution 
employed.  Not  more  than  three  applications  need  be  made,  within 
five  minutes,  before  operations  for  cataract,  etc.  Cocaine  has  been 
accused  of  producing  glaucoma,  but,  as  far  as  the  few  recorded 
cases  show,  without  much  reason.  For  deadening  granular  lids, 
or  similar  conditions,  a  much  stronger  solution  must  be  painted, 
over  the  afl"ected  surface  (I  use  a  20  per  cent,  solution  or  the  solid 
salt).  For  small  tumors  about  the  lid,  etc.,  a  4  per  cent,  solution 
is  injected  in  ditl'erent  directions  at  the  base  of  the  growth. 

Lamella  Cocain^e  (B.  P.  1SS5)  2^0  S^"-  ^"  each. 

If  the  eye  be  congested  or  inflamed  cocaine  acts  much  less  per- 
fectly on  the  conjunctiva;  but  it  acts  as  well  upon  an  ulcerated  as 
upon  a  healthy  cornea.  As  the  cocaine  takes  effect  only  on  the  part 
which  it  touches,  the  solution  must  be  made  to  flow  all  over  the 
cornea  and  conjunctiva  ;  and  as  it  penetrates  little,  if  at  all,  it  must 
be  injected  under  the  conjunctiva  if  we  wish  to  render  the  later 
(tenotomy)  stage  of  a  squint  operation  painless,  or  to  excise  the 


APPENDIX.  483 

eyeball  under  its  influence.  Cocaine  as  ordinarily  used  does  not 
seem  to  affect  tiie  sensibility  of  the  iris,  at  any  rate  no  such  action 
has  been  proved  ;  injection  into  the  anterior  chamber  for  this  pur- 
pose is  not  practicable,  even  if  safe. 

Cocaine  is  used  in  acute  iritis  in  conjunction  ^yith  atropine,  with 
the  idea  that  it  will  assist  the  anodyne  and  mydriatic  effects  of  the 
latter.  My  own  experience  does  not  enable  me  to  speak  strongly 
on  this  point. 

For  producing  rapid  but  brief  paralysis  of  Ace.  (in  ametropia)  a 
solution  containing  2  per  cent,  of  cocaine  and  2  per  cent,  of  homa- 
tropine  is  recommended  by  Mr.  Lang,  and  is  convenient  in  suitable 
eases  ;  the  maximum  effect  is  gained  in  from  20  to  60  minutes,  but 
soon  begins  to  decline. 

Faiutness  and  other  signs  of  nervous  depression  have  been  re- 
ported as  due  to  cocaine,  even  when  used  to  the  eye  alone.  I  believe 
that  these  symptoms  are  generally  due  to  reaction  after  the  mental 
strain  attending  an  operation  of  which  the  patient  is  conscious  ; 
for  before  cocaine  was  used  we  were  familiar  with  the  occurrence 
of  faintness  and  vomiting  from  time  to  time  when  eye  operations 
had  been  undergone  without  anaesthesia. 

Mtdkiatics  and  Myotics  : 

31.  (1)  Strong  Atropine  Drops: 

Liquor  Atropinse  Sulphatis  (B.  P.) 
(Sulphate  of  Atropia  gr.  ix, 
Camphor  water  gxvjss). 

Used  in  cases  where  the  rapid  and  full  local  action  of  the  drug 
is  required.  For  many  purposes  atropine  drops  may  be  used  con- 
siderably weaker  than  the  above.  Atropine  (a  single  drop,  of  2 
grains  to  gj;  or  about  0.5  per  cent.)  begins  to  dilate  the  pupil  in 
about  fifteen  minutes,  and  to  paralyze  the  accommodation  a  few 
minutes  later  ;  it  produces  wide  dilatation  of  the  pupil  (S  to  9  mm.) 
in  30  to  40  minutes,  and  full  paralysis  of  accommodation  in  about 
2  hours.  Both  remain  at  their  height  for  24  hours,  and  the  effect 
does  not  pass  off  entirely  until  from  3  to  7  days,  the  accommoda- 
tion recovering  rather  sooner  than  the  pupil.  If  stronger  solutions 
be  used  several  times,  the  action  continues  longer.  The  effects  of 
atropine  are  only  very  temporarily  and  imperfectly  overcome  by 
eserine.  Atropine  slightly  lowers  the  tension  of  the  healthy  eye, 
but  usually  increases  the  tension  in  glaucoma. 


484  APPENDIX. 

(2)   Weak  Atropine  Drops  : 

Sulphate  of  Atropia  gr.  ^'^  to  |, 
Distilled  water  5J. 

Used  when,  for  optical  purposes,  it  is  desired  to  keep  the  pupil 
dilated  for  a  long  time,  as  in  iraraature  nuclear  cataract.  A  single 
drop  about  three  times  a  week  will  generally  suffice.  Very  weak 
atropine  acts  naore  on  the  pupil  than  on  the  accommodation. 

Solutions  of  sulphate  of  atropine  keep  for  an  indefinite  time  ; 
the  flocculent  sediment  which  often  forms  does  not  impair  their 
efficiency.  The  mydriatics  and  myotics  may  be  used  in  the  form 
of  ointment  with  vaseline  or  castor  oil,  and  a  smaller  percentage 
of  the  drug  is  then  necessary  ;  the  alkaloids  themselves  must  be 
used,  their  salts  not  being  soluble  in  fats  and  oils. 

(3)  Ung.  Atropinm  (H.  P.  1885)  : 

Atropine  gr.  viij, 
Rect.  Spirit  5ss, 
Benzoated  Lard  ,5J« 

This  ointment  is  needlessly  strong  for  most  purposes  ;  1  grain 
to  1  ounce  is  usually  enough. 

(4)  Lamellce  Atropince  (B.  P.  1885)  ^-^^-^  gr.  in  each. 

32.  Daturine : 

Sulphate  of  Daturia  gr.  iv, 
Distilled  Water  §j. 

Used  as  a  mydriatic  in  cases  where  atropine  causes  conjunctival 
irritation. 

33.  Duboisine : 

Sulphate  of  Duboisia  gr.  j. 
Distilled  Water  §j. 

A  mydriatic,  acting  more  quickly  and  powerfully,  and  passing 
ofi"  in  a  shorter  time,  than  atropine.  It  is  tolerated  in  cases  where 
atropine  causes  conjunctivitis.  To  be  used  with  caution,  as  well- 
marked  toxic  symptoms  are  sometimes  caused. 

Duboisine  begins  to  act  on  the  pupil  and  accommodation  in  less 
than  ten  minutes,  produces  full  mydriasis  in  less  than  twenty 
minutes,  and  complete  cycloplegia  in  about  one  hour.  The 
maximum  effect  does  not  last  quite  so  long  as,  and  the  eflfect  passes 
off  completely  rather  sooner   than,  that  of   atropine.     Duboisine 


APPENDIX.  485 

seldom  breaks  down  iritic  adhesions  which  have  already  resisted 
atropine.  Its  chief  use  seems  to  be  for  cases  in  which  atropine 
causes  irritation. 

34.  Homatropine : 

Hydrobromate  of  Homatropine,  gr.  iv, 
Distilled  Water  gj. 

A  mydriatic,  acting  rather  more  quickly  and  passing  off  much 
sooner  than  atropine  ;  very  convenient,  therefore,  for  dilating  the 
pupil  for  ophthalmoscopic  examination. 

Homatropine  begins  to  act  on  the  pupil  and  accommodation  in 
from  five  to  fifteen  minutes  ;  the  greatest  dilatation  of  pupil 
(usually,  however,  rather  less  than  that  obtained  by  atropine)  is 
reached  in  about  fifty  minutes,  and  complete  or  nearly  complete 
cycloplegia  in  an  hour  or  rather  less  (with  the  solution  of  gr.  iv  to 
5j).  The  full  efi"ect  is  only  maintained,  however,  for  an  hour, 
more  or  less,  and  both  pupil  and  accommodation  usually  recover 
completely  in  twenty-four  hours  or  less.  Its  action  is  quicker  and 
rather  more  powerful  if  it  be  used  with  cocaine.     See  Cocaine. 

35.  Eserine  (Physostigmine)  (alkaloid  of  Calabar  Bean)  : 

(1)  Sulphate  of  Eseria  gr.  iv. 
Distilled  Water  gj. 

Used  in  mydriasis  and  paralysis  of  the  accommodation,  whether 
caused  by  atropine  or  by  nerve-lesions  in  some  forms  of  corneal 
ulcer  and  in  acute  glaucoma. 

(2)  A  weaker  solution  (gr.  j  to  ^j)  is  often  better  borne. 

Eserine  begins  to  contract  the  pupil  and  cause  spasm  of  the 
accommodation  in  about  five  minutes  ;  its  maximum  eflect  is 
reached  in  twenty  to  forty-five  minutes.  Its  full  eflfect  on  the 
accommodation  lasts  only  an  hour  or  two,  but  the  pupil  does  not 
completely  recover  for  many  hours,  sometimes  two  or  three  days. 
A  very  weak  solution  acts  more  on  the  pupil  than  on  the  accom- 
modation. Eserine  causes  pain  in  the  eye  and  head,  arterial  ciliary 
congestion,  and  twitching  of  the  orbicularis  ;  the  pain,  sometimes 
severe,  seldom  lasts  long.  Eserine  often  lessens  the  tension  in 
primary  glaucoma. 

(3)  Lamellce   Physostigmine^    (B.    P.    1885)    jqVo   g^-    ^^ 

each. 


486  APPENDIX. 

All  the  mydriatics  and  myotics  may  be  obtained  in  the  form 
of  small  gelatine  discs  of  known  strength  (made  by  Savory  and 
Moore,  and  by  Martindale),  which  are  sometimes  more  convenient 
than  the  solutions.  Of  the  mydriatics,  horaatropine  and  duboisine 
are  much  the  most  expensive. 

36.  Belladonna  Fomentation : 

Extract  of  Belladonna  5i  to  ij, 
Water  Oj. 

Warmed  in  a  cup  or  small  basin,  and  used  as  a  hot  fomentation 
in  suppurating  and  serpiginous  ulcers  of  cornea. 

37.  Pilocarpine  for  Subcutaneous  Injection  : 

Hydrochlorate  of  Pilocarpine  gr.  v, 
Distilled  Water  3j' 

Dose,  Tr^iij,  gradually  increased,  to  be  injected  daily  or  less  often. 
Used  in  cases  of  retinal  detachment,  choroiditis,  and  retinitis. 

38.  Pilocarpine  Drops:  gr.  iv  to  5J. 

Pilocarpine  is  a  myotic,  like  eseriue,  but  its  action  is  much 
weaker. 

39.  Steychxia  for  Subcutaneous  Injection : 

Liquor  Strychninse  (B.  P.)  gr.  iv  to  §j. 

Dose,  two  minims  (-^^  grain),  gradually  increased,  for  subcu- 
taneous injection.     To  be  injected  once  a  day. 

40.  "  Jequirity"  seeds,  obtained  from  a  leguminous  plant,  are 
used  in  South  America  for  tlie  cure  of  granular  lids.  They  can 
now  be  readily  obtained  in  moderately  fine  powder.  The  infusion 
is  made  by  soaking  the  powder  in  cold  water  for  a  couple  of  hours, 
or  better,  in  water  at  120O  F.,  allowing  it  to  stand  till  cool,  and 
straining  through  muslin  ;  it  is  then  ready  for  use,  but  will  remain 
active  for  several  days.  When  obviously  decomposed  (fetid)  it  is 
no  longer  active.  The  simple  powder  dusted  into  the  conjunctiva 
is  said  to  be  active,  but  two  or  three  trials  which  I  made  with  it 
were  negative. 

The  action  of  Jequirity  probably  depends  upon  a  nitrogenous 
ferment — not,  as  was  for  a  time  believed,  upon  a  specific  microbe. 
A  substance  possessing  the  peculiar  properties  of  the  natural  seed 


APPENDIX.  48*7 

has  been  separated  by  more  than  one  experimenter,  but  does  not 
appear  to  be  procurable  in  the  market ;  it  is  difficult  to  make,  and 
its  composition  seems  to  varj. 

As  the  intensity  of  action  of  Jequirity  infusions  of  the  same 
strength  varies  very  much  in  different  persons,  and  is  sometimes 
very  severe,  it  is  best  to  use  a  weak  preparation  (1  grain  of  powder 
in  100  grains  of  water,  or  5i  to  fl.gxijss)  for  all  cases  at  first.  A 
single  prolonged  application,  or  several  applications  within  a  few 
minutes,  to  the  everted  lids  will  suffice. 

41.  Bandages  for  the  eyes  may  be  of  thin  flannel  or  soft 
calico.  A  linen  or  cotton  bandage,  about  ten  inches  long,  with 
four  tails  of  tape,  or  a  loop  of  tape  embracing  the  back  of  the 
head  (Liebreich's  bandage),  is  very  convenient  after  the  more 
serious  operations.  An  ordinary  narrow  flannel  bandage  is  better 
when  much  pressure  is  wanted,  or  if  the  patient  be  unruly.  The 
soft,  elastic,  woven  bandage,  known  as  the  "Leicester"  bandage, 
is  even  pleasanter  than  flannel. 

When  absolute  exclusion  of  light  is  desired,  it  is  best  to  use  a 
bandage  made  of  a  double  fold  of  some  thin  black  material. 

Fine  old  linen  is  better  than  lint  for  laying  next  the  skin  in 
dressings  after  operations. 

42.  Shades  may  be  bought  at  the  opticians'  and  chemists'  ; 
or  may  be  made  of  thin  cardboard  covered  with  some  dark  mate- 
rial, or  of  stout  dark-blue  paper,  like  that  used  for  making  grocers' 
sugar  bags.  Shades  of  black  plaited  straw  are  also  very  light  and 
convenient. 

Shades,  to  be  effectual,  should  extend  to  the  temple  on  each  side, 
so  as  to  exclude  all  side  light. 

43.  Protective  Glasses. 

Various  patterns  of  glasses  are  made  for  the  purpose  of  protect- 
ing the  eyes  from  wind,  dust,  and  bright  light.  The  glasses  are 
either  flat,  or  hollow  like  a  watch-glass,  and  are  colored  in  various 
shades  of  blue  or  smoke  tint.  The  most  effectual  are  the  ones 
known  as  "goggles  ;"  in  these  the  space  between  the  glass  and  the 
edge  of  the  orbit  is  filled  by  a  carefully-fitting  framework  of  fine 
wire  gauze  or  black  crape,  by  which  side  wind  and  light  are 
excluded.  A  small  air  pad  of  thin  India-rubber  tubing  makes 
the  frame  fit  still  more  closely. 


488  APPENDIX. 

Otlier  forms,  kiiDWii  as  "  horseshoe'"  or  "D,"  and  "domed"  or 
"hollow"  glasses  are  also  iu  common  use. 

44.  Test  Types. 

Snellen's  types  for  testing  both  near  and  distant  vision  under 
an  angle  of  five  minutes  can  be  obtained  through  Queen  &  Co., 
924  Chestnut  St.,  Philadelphia. 

The  types  which  I  generally  use  for  testing  near  vision  are  those 
used  at  the  Moorfields  Hospital,  where  they  may  be  obtained. 
They  can  also  be  bought,  conveniently  mounted,  of  Queen  &  Co., 
924  Chestnut  St.,  Philadelphia.  These  types  nearly  resemble  those 
of  Jaeger,  and  though  less  correct  theoretically  than  the  corre- 
sponding type  of  Snellen's  scale,  are  more  convenient  in  practice 
for  testing  the  reading  power.  There  are  several  other  sets  of 
test  types  which  it  is  unnecessary  here  to  particularize. 

A  convenient  set  of  tests,  small  enough  to  be  carried  in  the 
pocket,  can  be  obtained  through  Queen  &  Co.,  924  Chestnut  St., 
Philadelphia.  It  consists  of  types  for  near  and  distant  vision,  a 
pupillcmeter  for  measuring  the  pupil,  a  set  of  colored  stuffs  for 
color-blindness,  and  a  small  series  of  lenses  for  testing  refraction. 
This  case  is  intended  chiefly  for  ward  work  and  general  medical 
cases.      It  may  be  also  bought  without  the  lenses. 

45.  Ophthalmoscopes. 

It  is  impossible  to  say  that  any  ophthalmoscope  is  the  best. 
When  expense  is  not  a  great  object,  it  is  always  better  to  have  one 
of  the  so-called  "  refraction  ophthalmoscopes."  In  these  a  number 
of  small  lenses  are  placed  in  a  disc  behind  the  mirror,  the  disc 
being  made  to  revolve  by  finger  pressure  so  as  to  bring  the  lenses 
one  after  another  opposite  the  sight-hole.  For  medical  ophthal- 
moscopy it  is  not  essential  to  have  so  many  lenses  ;  about  four 
concave  and  two  convex  will  enable  an  erect  image  to  be  easily 
obtained  in  most  cases;  Lieb.'-eich's  "small"  ophthalmoscope  and 
Oldham's  ophthalmoscope  are  both  very  convenient  forms  for  such 
use,  and  cost  less  than  half  as  much  as  the  refraction  instruments. 
Every  ophthalmoscope  case  should  contain  two  large  "objective" 
lenses  for  the  indirect  examination,  focal  illumination,  and  mag- 
nifying ;  one  may  be  of  2^,  the  other  3^  inches  focus.  For  the 
detection  of  incipient  opacities  in  the  lens,  for  direct  examination 
without  atropine,  and  for  retinoscopy,  a  plane  mirror  is  very  useful 


1 


N 


O 
^ 
^ 


> 

z 


I 

f 


Lr 

160  128 


U     E      Z 

Y      P    N  VDFl 


APPENDIX.  489 

in  addition  to  the  ordinary  concave  one.  It  gives  a  weaker  illu- 
mination. Such  a  plane  mirror  may  be  had  cheaply  as  a  separate 
instrument  for  the  waistcoat  pocket,  but  I  much  prefer  it  and  the 
concave  one  for  indirect  examination,  mounted  back  to  back  (see 
below). 

Of  the  refraction  ophthalmoscopes  there  are  now  a  great  many 
patterns,  differing  in  the  number  and  size  of  the  lenses,  the  size  of 
the  mirror  and  lens-bearing  disc,  and  other  details.  Usually  the 
disc  contains  20  to  24  lenses,  and  one  empty  circle.  In  the  simpler 
forms  about  half  the  lenses  are  +  and  half — .  But  in  others  the 
number  of  powers  is  immensely  increased  by  combining  lenses  of 
different  strengths,  e.  g.,  the  disc  may  contain  24  -f-  lenses,  whilst  a 
single  movable  —  lens,  rather  stronger  than  the  highest  +,  is  placed 
behind  the  disc  over  the  sight-hole  ;  by  placing  it  opposite  the 
sight-hole  and  then  bringing  the  various  +  lenses  over  it  in  suc- 
cession, a  series  of  25  —  powers,  or  49  in  all,  will  be  obtained.  In 
order  to  avoid  the  error  caused  by  looking  obliquely  through  a  lens, 
all  the  better  instruments  (e.  g.,  Loring's,  Couper's,  Morton's,  and 
others)  are  so  arranged  that  the  mirror  can  be  suflSciently  inclined 
to  receive  the  light,  whilst  the  lens-bearing  disc  remains  at  right 
angles  to  the  observer's  line  of  sight.  Generally  speaking,  the 
English  and  American  instruments  are  much  better  made  than  the 
French.  Of  the  simpler  forms  with  only  one  mirror,  the  one 
introduced  by  Dr.  Gowers  is  fairly  efficient.  Of  the  more  expen- 
sive forms,  several  good  ones  have  been  derived  from  an  early 
model  by  Mr.  Laidlaw  Purves,  both  of  which  may  be  procured 
from  Queen  &  Co.,  924  Chestnut  Street,  Philadelphia.  The  latest 
form  of  this  instrument,  made  by  Mr.  Ferrier  for  myself,  has  three 
mirrors  (two  of  them  back  to  back  in  a  single  ring)  mounted  on  a 
rotating  carriage  like  the  "nose-piece"  of  a  microscope;  it  is  ex- 
tremely convenient  and  accurate.  For  the  application  of  the 
"nose-piece"  principle  to  the  ophthalmoscope  we  are  indebted  to 
Mr.  Lindsay  Johnson.  Mr.  Couper's  and  Mr.  Morton's  models 
are  very  excellent  and  deservedly  popular.  In  a  good  refraction 
ophthalmoscope  the  mirror  should  be  thin  and  the  sight-hole  per- 
forated ;  the  lens-disc  thin  and  working  as  close  to  the  back  of  the 
mirror  as  possible  ;  the  lenses  evenly  mounted,  centred  truly,  either 
thoroughly  covered  up  or  easily  accessible  for  cleaning,  and  not 
less  than  5  mm.  in  diameter. 

21* 


490  APPENDIX. 

46.  Perimeters. 

The  most  convenient  forms  have  an  arrangement  for  registering 
the  field  automatically  on  a  chart  fixed  behind  the  centre  of  the 
are>  A  very  complete,  but  complicated  and  expensive,  one,  is 
McHardy's  ;  Priestley  Smith's,  much  simpler  and  cheaper,  is  for 
most  purposes  as  useful.  Blix's  self-registering  perimeter  is  well 
spoken  of  by  Dr.  Berry.  All  of  which  may  be  obtained  from 
Messrs.  Queen. 

47.  The  "Clock-face"  for  testing  astigmatism  can  be  had 
at  Queen's. 

48.  The  set  of  Colored  Wools  recommended  by  Prof.  Holm- 
gren, af  Upsala,  for  testing  color-blindness,  can  be  obtained  for 
about  81.50,  from  Queen  &  Co. 

In  the  colored  plate  copied  by  permission  from  Prof.  Holmgren's 
work,  De  la  Cecite  cles  Couleurs,  etc.,  1877,  the  horizontal  stripes  I, 
Ila,  and  116,  show  the  colors  which  it  is,  as  a  rule,  most  convenient 
to  use  as  tests  ;  and  the  short  vertical  stripes  are  the  colors  most 
likely  to  be  confused  with  these  by  those  afi!'ected  with  the  ordinary 
forms  of  color-blindness.  Thus,  No.  1  will  be  confused  with  one 
or  more  of  such  buffs,  pinks,  etc.,  as  Nos.  1  to  5  ;  in  slight  de- 
grees of  color-defect  the  confusions  will  be  limited  to  these  pale 
colors. 

In  higher  degrees  of  color-blindness  stronger  or  more  saturated 
colors  will  be  confused  ;  Ila,  for  example,  or  even  a  stronger  rose 
color,  may  be  confused,  on  the  one  hand,  with  a  full  blue  or  purple, 
Nos.  6  and  7  ;  or,  on  the  other,  with  a  full  gray  or  green,  Nos.  8  and 
9.  Taking  a  diff"erent  series  of  equally  saturated  colors,  the  scarlet 
lib  may  be  confidently  identified  with  dark  green  or  brown,  Nos. 
10  and  11,  or  with  light  bright  green  and  yellow-brown,  Nos.  12 
and  13. 

The  confusion  colors,  Nos.  1  to  13  on  the  plate,  are  given 
merely  as  samples  of  the  colors  most  commonly  confused  with  the 
respective  test-colors  ;  iji  practice  a  much  larger  series  should  be 
employed;  the  more  critical  the  patient,  the  larger  is  the  number 
of  shades  and  colors  requisite  ;  even  markedly  color-blind  persons 
do  not  always  match  exactly  the  same  colors  with  the  tests.  Colored 
worsteds  are  used  because  it  is  easier  to  obtain  a  very  large  series 
in  this  material  than  in  any  other. 

The  manner  in  which  a  color-blind  person  behaves  will  often  ex- 


3  4  5 


I     I    II 


II  a. 


6  7 


II 


8  9 


II 


ir  b. 


10  11 


II 


ii  18 


II 


[See  page  490. 


APPENDIX..  491 

cite  suspicion  of  his  defect.  He  will  perhaps  place  doubtfully  side 
by  side  with  I,  such  a  color  as  No.  2  or  5,  to  see  whether  or  not 
they  are  alike,  and  finally  will  decide  that  they  are  not  quite  of 
the  same  color,  though  "rather  alike."  In  such  cases,  and  again 
in  others,  where  perhaps  the  patient  does  not  understand  what  is 
wanted,  the  diagnosis  may  often  be  made  certain  in  the  following 
manner:  Take  two  colors  over  which  the  patient  is  stumbling,  or 
on  which  he  cannot  express  himself,  say  Nos.  Ha  and  a  lighter 
shade  of  9,  add  a  third  of  the  same  dominant  color  as  9,  but  of  a 
markedly  different  shade,  such  as  10  or  12 ;  now  ask  him  which 
pair  is  more  alike,  Nos.  lla  and  9,  or  Nos.  9  and  10  ;  if  he  says 
Ila  and  9  are  more  alike  he  is  color-blind,  and  is  judging  of  their 
similarity  by  the  shade,  that  is,  the  amount  of  white  contained  in 
each  of  them,  and  not  by  their  color.  It  is  easy  to  vary  this  test 
according  to  the  requirements  of  the  case. 

Another  good  method  is  to  tell  the  patient  to  pick  out  all  the 
skeins  of  one  color,  say  green,  without  requiring  him  to  match  them 
precisely  with  any  test  skein  ;  if  decidedly  color-blind,  he  will  con- 
fidently select  not  only  those  which  are  green,  but  a  number  of 
others,  usually  gray  ones.  Or  we  may  say  :  "Do  you  see  any 
green  skeins  among  them  ?"  If  color-blind  lie  will  say  "No,"  or 
hesitate,  or  make  the  same  mistakes  as  above. 

A  special  arrangement  of  the  wools,  enabling  a  quick,  accurate, 
and  uniform  record  of  color-perception  to  be  made,  has  been  de- 
signed by  Dr.  William  Thomson,  of  Philadelphia,  and  is  obtain- 
able from  Queen  &  Co.     (Supplement,  page  465.) 

Of  the  many  other  tests  for  color-blindness  the  following  may 
be  mentioned  : 

Stilling's  Tables  consist  of  colored  letters  or  patterns  printed  on 
a  groundwork  of  one  of  the  "confusion  colors."  They  are  pre- 
ferred by  some  to  Holmgren's  wool. 

Donders's  method  determines  the  color-sense  (or  color-defect) 
quantitatively  by  means  of  a  light  of  known  intensity,  which 
passes  through  apertures  filled  by  diflferently  colored  glasses  ;  these 
are  recognized  at  a  specified  distance  if  the  color-sense  is  normal. 

Mr.  Jeaffreson  (of  Newcastle)  has  lately  constructed  an  ingenious 
apparatus  in  which  the  colored  wools,  fixed  in  radii  upon  a  rotating 
disc,  can  be  successively  brought  opposite  to  stationary  patches  of 
the  respective  confusion  colors,  which  are  placed  just  beyond  the 
circumference  of  the  disc  :   Lancet,  July  17,  1886. 


492  APPENDIX. 

Bull  (of  Cliristiauia)  has  introduced  a  quantitative  test,  based 
upon  the  smallest  amount  of  color  which,  mixed  with  gray,  can 
be  recognized  by  the  normal  eye.  (Obtainable  from  Queen  &  Co.) 
Rows  of  colored  spots,  those  in  each  row  containing  a  different 
quantity  of  gray,  are  painted  in  oil  colors  on  a  black  background. 
The  normal  eye  will  distinguish  the  colors  even  in  the  grayest 
row;  the  color- blind  will,  according  to  the  degree  of  defect,  con- 
fuse complementary  colors  in  some  or  all  of  the  rows.  I  find 
Bull's  tables  very  useful,  but  like  all  painted  and  lithographed 
surfaces  they  reflect  too  much  light,  and  thus,  unless  held  exactly 
in  the  right  position,  they  shine  and  their  color  is  altered.  Unless 
very  carefully  used.  Bull's  and  Jeaffreson's  tests  are,  I  think,  less 
trustworthy  than  a  good  set  of  wools. 


An  explanation  of  the  colored  plate  is  given  on  p.  490  ; 
it  is  not  intended  to  be  used  as  a  test,  but  only  as  an  illus- 
tration of  the  colors  commonly  confused. 


I  X  D  E  X 


Abbreviations.  25 
Aberratiou,  chromatic,  61 

spherical,  30 
Abrasion  of  cornea,  132,  181 
Abscess,  episcleral,  165 

of  cornea,  133 

of  lachrymal  gland,  319 
sac,  101,  103 

orbital,  318 
Abscission  of  eyeball,  402 
Accommodation,  errors,  326 

examination,  49 

in  myopia,  327 

influence  of  age  npon,  361 

paralysis  of,  377 

region  and  range  of,  361 

relative,  50 

spasm  of,  330 
Accommodative  asthenopia,  273, 

343 
Action    of    drugs    on    iris    and 

ciliary  muscle,   374 
Acuteness  of  sight,  48 
Advancement  of  muscle,   opera- 
tion for,  399 

of  Tenon's  capsule,  401 
Albinism.  225 
Albuminuric  retinitis,   230,   238, 

439 
Alcohol,  amblyopia,  437 
Amaurosis,  264 

single,  262 
Amblyopia,  264 

alcohol,  437 

bisulphide  of  carbon  in,  438 

central,  267 

congenital,  264 

diabetic,  440 

from    defective    retinal    im- 
ages, 266 


Amblyopia    from    injury   to   one 
eye,  274 
from  suppression  of  images, 

264 
hereditary,  269 
hysterical,  272 
in  ametropia,  266 
I  potatorum,  437 

I  quinine,  439" 

I  tobacco,  269,  437 

Ametropia    {any  permanent    error 

in  refraction  of  the  eye),  326 
Amyloid  of  conjunctiva,  123 
Anaemia,  pernicious,  eye  diseases 

in,  441 
Anaesthesia   in  ophthalmic   sur- 
gery, 426 
of  retina,  272 
Angle  of  emergence,  27 
of  incidence,  27 
visual,  38 
a,  58 
An-iso-metropia       {unequal       re- 
fraction in  the  two  eyes),  358 
Anterior  chamber,  foreign  body 
I  in,  405 

I  in  paracentesis,  405 

focus  of  eye,  39 
polar  cataract,  193 
;  staphyloma,  167 

j  Apparent  size  of  objects,  61 
j  Aqueous,  turbidity  of,  153 
I  Arcus    inflammatory,  150 
i  Arcus  senilis,  149 
Argyll     Robertson's      svmptom, 

452 
Arlt's    operation    for    entropion, 

385 
Arterial  pulsation,  441 
Artificial  eye,  402 


494 


1  NDBX. 


Artiacial  pupil,  408 

vitreous,  403 
Asthenia  retime,  273 
Asthenopia     {weakness    of    eyes; 
any   condition  in    which    the 
eyes  cannot  be  used  for  long 
together),  273 
accommodative,  273,  343 
muscular,  273,  367 
Astigmatism,  34!) 

after  extraction   of  cataract 

and  iridectomy,  2U6,  351 
causes  of,  352 
clock-face  for,  355 
detection  of,  80,  87 
irregular,  352 
methods  of  testing,  354 
principal  meridian,  351 
regular,  351 
traumatic,   181 
visual  acuteness  in,  358 
Atrophy  of  choroid,  212,  215 
in  myopia,  334 
optic     (see    also    Neuritis), 
257 
after  embolism,  243 
after  neuritis,  253 
after    orbital   cellulitis, 

457 
clinical  aspects  of,  258 
fields  of  vision  in,  260 
from  pressure,  258 
in  ataxy,  2G1,  451 
in  hydrocephalus,  258, 

450 
post-papillitic,  253 
primary,  258,  451 
prognosis  in,  260 
progressive,  258,  451 
pupils  in,  260 
sight  in,  259 
uniocular,  262 
varieties  of,  258 
Atropine,  action  on  healthy  eye, 
50,  51,  483 
effect  on  tension,  483 
in  cataract,  200 
in  corneal  ulcers,  136,  139 
in  glaucoma,  298 
in  iritis,  160 
irritation,  124 
Axial  myopia,  328 


Axis,  optic,  58 

principal,  of  a  lens,  29 
secondary,  of  a  lens,  29 
visual,  of  eye,  38,  58 

Badal's  operation,  404 
Bandages,  487 

after     cataract     operations, 

422 
after  excision  of  eye,  401 
in  iritis,   161 
in  ophthalmia,  111 
in  ulcers  of  cornea,  138 
Basedow's  disease,  455 
Binocular  field  of  vision,  46 
Bisulphide  of  carbon,  amblyopia 

from,  438 
Black  eye,  317 

Blennorrhoea  of  conjunctiva,  105 
Blepharitis,  91 

treatment  of,  94 
Blepbaroplasty,  389 
Blepharospasm,  128 
Blindness    of    one    eye,     undis- 
{      covered,  266 

I  Blinking,  in  hypermetropia,  343 
Blood  in  A.  C,  153,  179 
I  in  vitreous,  284 

:  Bloodvessels  of  choroid,  212 
i  of  eye,  external,  52 

of  retina,  74,  226 
Blows  on  the  eye,  179 
Bone  in  eye,  44 
,  Bony  tumor  of  lid,  309 

Brain  (see  Cerebral). 
I  Buller's  shield,  108 
Buphthalmos,  149 
Burns  of  eye,  182 
Burow's  operation,  384 

Canaliculus,  diseases  of,  100 

operations,  392 
Cancer,  rodent,  96 
Canthoplasty,  390 
Canthotomy,  136 
Capsulo-pupillary       membrane, 

163 
Cataract,  189 

artificial  maturation  of,  202 

atropine  in,  200 

cause  of,  190 

concussion,  207 


INDEX 


495 


Cataract,  congenital,  199 
consistence  of,  189 
cortical,  190,  196 
diabetic,  440 
diagnosis,  194 
discission,  200,  424 
dotted  cortical,  191 
extraction,  200,  415 

after  operations,  205 
causes  of  failure,  203 
history,  421 
iritis  after,  204 
suppuration  after,  203 
forms  of  general,  190 
glasses,  206 
hard,  190 
immature,  195 
in  myopia,  200,  335 
lamellar,  191,  197,  206,  459 
mature,  195 
mixed, 190 
Morgagnian,  199 
nuclear,  190 
operations,  200,  415 
over-ripe,  199 
polar,  anterior,  193 

posterior,  193,  197 
primary,  194 
prognosis,  199 
pyramidal,  192 
ripening  of,  202 
secondary,  194 
senile,  190 
sight    after    removal,    199, 

206 
soft,  191 

solution,  200,  424 
suction,  201 
symptoms,  194 
traumatic,  184,  207 
treatment,  209 
zonular  {see  Lamellar). 
Catarrhal  ophthalmia,  111 
Caustics,  injuries  by,  182 
Cavernous  sinus,  thrombosis  of, 

319 
Cellulitis  of  orbit,  318,  457 
Central  choroiditis,  222 

nervous  system,  eye  diseases, 

448 
scotoma,  268,  441 
Centre  of  rotation  of  eye,  39 


Cerebral  tumor,  neuritis  in,  255, 
448 
syphilis,  neuritis  in,  449 
Cerebritis,  neuritis  in,  450 
Cerebro-spinal    meningitis,    eye 

diseases,  435 
Clialazion,  94 
Chancre  on  conjunctiva,  97 

on  eyelids,  97,  429 
Cliemosis,  106 
Clierry-red  spot,  243 
Chicken-pox,  eye  disease,  434 
Chloride  of  zinc  paste,  479 
Cholesterin  in  vitreous,  283 
Chorio-capillaris,  211 
Choroid,  appearances  in  disease, 
212 
in  albinism,  225 
atrophy  of,  212 
colloid W,  217 
coloboma  of,  224 
congestion  of,  224 
diseases  of,  210 
hemorrhages  in,  218 
healtiiy,  211 
lamina  elastica,  218 
myopic  changes,  221 
nsevus  of,  325 
rupture,  179,  217 
sarcoma,  312 
tubercle,  216,  222,  442 
vessels  of,  74 
Choroidal    atrophy   in    myopia, 
221,  334 
disease  with  cataract,  222 
exudation,  216 
hemorrhages,  218,  334 
results,  222 
Choroiditic  atrophy  of  disc,  219 
Choroiditis,  anomalous  forms  of, 
222 
anterior,  166 
central  guttate,  223 

senile,  222 
disseminata,  219 
hemorrhagica,  224 
in  hydrocephalus,  450 
in  myopia,  221 
senile,  222 
superficial,  215 
syphilitica,  216 
Ciliarv  arteries,  52 


496 


I  N  LEX. 


Ciliary  body,  sarcoma  of,  312 

congestion,  54,  152 

muscle  in  astigmatism,  354 
in  myopia,  330,  335 
paralysis  of,   180.   377, 
433 

region,  diseases  of,  164 
Circumcorneal  zone,  54,  152 
Clear    sight,   optical    conditions, 

39 
Cocaine,  481 
Cold  in  iritis,  161 
Coloboma  of   choroid    (congenital 
cleft  in  choroid) ,  224 

of  iris  {deft  in   iris,  congeni- 
tal  or   the  result   of  iridec- 
tomy), 163 
Color-blindness,  278 

in  atrophy,  260 

tests  for,  461,  490 
Color-perception,  testing,  47,  461 
Colored  vision,  276,  461 
Colors,    field   of  vision    for,    46, 

279   _ 
*'  Commotio  retince.^  181 
Congenital  absence  of  iris,  162 

cataract,  199 

coloboma,  163,  224 

dermoid  cysts,  325 
tiunor,  308 

dislocation  of  lens,  208 

fibro-fatty  growths,  309 

irideremia,  162 

ptosis,  98 
Congestion,  choroidal,  224 

ciliary,  55 

circumcorneal,  54 

conjunctival,  55 

episcleral,  55 

in  iritis,  152 

of  optic  disc,  250 

of  retina,  229 

varieties  of,  52 
Conjunctiva,  amyloid  of,  123 

burns  of,  182 

cauliflower  warts  of,  307 

diseases,  105 

lupus  of,  307 

nitrate  of  silver  staining  of, 
151 

primary  shrinking  of,  125 

tubercle  of,  307 


Conjunctiva,  tumors  of,  307 
Conjunctivitis  (see  Ophthalmia). 
Contagion,     conjunctival,      105, 

110 
Convergent  squint  (see  Strabis- 
mus). 
Convulsions   and  lamellar  cata- 
ract, 454 
Coredialysis,  179 
Cornea,  abrasion,  132,  181 
abscess,  133 
burns,  182 
conical,  141 

operations  for,  407 
diseases  of,  126 
fluorescence  of,  127 
focal  length  of,  39 
foreign  body  in,  181 
ground-glass,  127 
herpes  of,  129 
inflammation  of,  126 
inspection  of,  43 
irregularity  of  surface  of,  43 
lead  deposit,  150 
operations,  404 
j  removal    of    foreign    bodies 

j  from,  404 

I  steaminess,  126,  149 

;  tj-ansplantation  of,  128 

transverse    calcareous    film, 

149 
tubercle  of,  316 
ulceration,  107,  126 
atropine  in,  139 
cauterization  of,  406 
crescentic,  132 
dendritic,  135 
eserine  in,  139 
fomentations,  138 
from  exposure,  140 
infective,  132 
in  meningitis,  140 
paracentesis,  138 
phlyctenular,  129 
section  for,  138 
serpiginous,  133 
seton  for,  137 
suppurating,  133 
treatment,  135 
varieties  of,  129 
vascular  recuirent,  131 
Crescents  in  astigmatism,  221 


N  D  E  X  . 


497 


Crescents  in  myopia,  221,  234 
Critcliett's  operation  for  squint, 
398  : 

Crystalline  lens,  spherical  aber- 
ration of,  30,  40 
focal  length  of,  39 
Cnp,  physiological,  72 
in  glaucoma,  291 
Cutaneous  horn,  95 
Cyclitis,  168 

suppurative,  170 
syphilitic,  430 

traumatic,   170  i 

Cyclo-iritis  {see  Sclero-).  j 

Cyclo-keratitis  (see  Sclero-).  j 

Cycloplegia    {paralysis   of  ciliary  ' 
nmsde),  ISO,  377,' 433 
diphtheritic,  433 
Cysticercus  cellulosse,  284,  447      , 
Cystic  tumors  in  lids  and  orbit, 

323  ! 

Cysts  of  conjunctiva,  308,  309 

of  iris,  315  i 

of  margins  of  lids,  95  ] 

Dackvo-cystitis,      clironic      {in-  \ 
Jlarnmation    of    lachrymal     sac). 
101  i 

Dacryo-liths,  100  i 

Dacryops,  309 

"  Dangerous  zone,"  172  i 

Daturine,  484  I 

Day-blindness,  276  ! 

Deceutred  lens,  36  i 

Delirium    after    eye    operations,  l 
422  I 

Dermoid  cysts  of  eyebrow,  325      ' 

tumor  of  eyeball,  308 
Detachment  of  retina,  234  ! 

in  myopia,  335 
Diabetes,  eye  diseases  in,  440 
Diabetic  amblyopia,  440  j 

cataract,  440  I 

retinitis,  440  I 

Dioptre,  40 
Dioptiic     system     of     spectacle 

lenses,  40 
Diphtheria,  eye  disease,  433 
Diphtheritic  paralysis  of  accom-  j 
modation,  433  ] 

of  recti  muscles,  433 
ophthalmia,  112,  433 


Diplopia  (see  also  Strabismus 
and  Paralysis),  60,  362, 
363 

binocular,  60 

chart,  371 

crossed,  365 

examination,  60 

homonymous,  345,  365 

uniocular,  60 
Direct  examination,  66,  75 
Discission  of  cataract,  200,  424 
Dislocation  of  lens,  181,  208 
Disseminated  choroiditis,  219 

sclerosis,  eye  diseases  in,  453 
Distichiasis,  120 
Double  sight,  60 
Drugs,  action  on  ciliary  muscle 

and  iris,  374 
Duboisine,  484 

EccHYMOSis  in  catarrhal  oph- 
thalmia, 110 

of  eyelids,  317 
Echinocoocus,  447 
Ectropion,  operations  for,  389 
Eczema,  marginal,  92 
Embolism  of  eye  in  pyaemia,  436 

of  central  artery,  242 
Emmetropia,  326 
Emphysema  of  orbit,  317 
Endemic  nyctalopia,  275 
Enophthalmos,  317 
Entozoa  in  eye,  447 
Entropion,  organic,  120,  383 

operations  for,  382 

spasmodic,  382 
Epicanthus,  98 
Epilation,  93,  381 
Epiphora,  92,  98 
Episcleritis,  164,  309 
Epithelioma  of  conjunctiva,  309 
"  Erect  image,"  67 
Erysipelas    of    face,     blindness 

from,  457 
Erythropsia,  276 
Eserine,  485 

action  on  healthy  eye,  485 

in  glaucoma,  299,  485 

in  mydriasis,  485 

in  ulcers  of  cornea,  139 
Eversion  of  upper  lid,  381 
Evisceration,  403 


498 


INDEX 


Examination,  focal,  63 

of  blooflvt'ssels  of  eye,  52 
of  color-perception,  46,  279, 

461 
of  cornea,  43 
of  eye,  external,  43 
of  field  of  vision,  44 
of  mobility  of   eye    (field  of 

fixation),  57 
of  pupils,  50 
of  railway  employes,  461 
of  refraction  of  eye,  78 
of  tension,  43 
ophthalmoscopic,  65 
direct,  {i6,  69 
indirect,  65,  69 
Excision  of  eye,  401 

in  sympathetic  disease, 

173,  176 
rules  for,  184,  305,  316 
Exclusion  of  pupil,  155 
Exophthalmic  goitre,  456 
Exophthalmos,  pulsating,  322 
Exostoses,  ivory,  of  orbit,  322 
Extraction      of      cataract      (see 

Cataract). 
Eye  disease  in   relation    to   gen- 
eral diseases,  429 
protrusion  of,  62 
refracting  surfaces  of,  38 
Eyeball,  foreign  bodies  in,  185 
Eyelids,  diseases  of,  91 
tooth  in,  309 
tumors,  307 
bony,  309 
fibrous,  309 
wounds  of,  320 

Facial  nerve,  paralysis  of,  455 

"  False  image,"  60,  369 

"  Far  point,"  50 

Feigned  blindness,  37,  277 

Fibro-fatty  growth,  309 

Field  of  fixation,  57 

of  vision,  44 
Fifth-nerve  paralysis,  455 
Filtration  scar,  301 
Flap  extraction,  420 
Flittering  scotoma,  447 
Focal  illumination,  63 

interval,  351 
Focus,  anterior,  of  eye,  38 


Focus,  conjugate,  of  a  lens,  31 
principal,  of  a  lens,  30 
viitual,  of  a  lens,  31 
Foreign  body  in  eye,  185 
in  orbit,  320 
on  cornea,  181 
Forster's  operation,  202 
Fourth-nerve  paralysis,  370,  377 
Foren  centralis,  74,  227 
Fracture  of  orbit,  317,  320 
BVontal  sinus,  distention  of,   321 
Functional    disorders    of    sight, 

264 
Fundus,  central  region  of,  74 
of  eye,  definition,  67 
examination  of,  69 
Fungus  in  canaliculus,  100 
Fusion  power  of  ocular  muscles, 
36 

Gelatinous    exudation    in     an- 
terior chamber,  153 
General  diseases  causing  eye  dis- 
ease, 429 

paralysis  of  insane,  eye  dis- 
eases, 451 
Giddiness  from  ocular  paralysis, 

372 
Glasses,  protective,  487 

(see  Spectacles). 
Glaucoma,  286 

absolute,  290 

acute,  289 

after  extraction  of  cataract, 
304 

atropine  in,  298 

causes,  298 

chronic,  287 

cornea  in,  148,  289 

cupping,  291 

eserine  in,   299 

field  of  vision  in,  289 

hemorrhagic,  305 

"intlammatory,"  288 

malic/num,  304 

mechanism,  294 

neuralgia  preceding,  298 

operations,  299,  409 

premonitory  stage,  287 

primary,  286 

prognosis,  302 

remittent,  289 


INDEX. 


499 


Glaucoma,  sclerotomy,  300 
secondary,  157,  2S6,  304 

to  anterior  synechia,  304 
to   cataract    extraction, 

304 
to   dislocation    of   lens, 

20S,  304 
to    posterior    synechia, 

157 
to    sympathetic     iritis, 

174,  304 
to  tumor,  305,  314 
second  operation,  303 
simplex,  288 
subacute,  288 
theory  of  iridectomy,  299 
treatment,  299 
vitreous  humor  in,  295 
(rlioma  of  retina,  310  i 

Goitre,  exophthalmic,  456 
Gonorrhoeal  ophthalmia,  105  ' 

rheumatic  iritis,  444 
Gout,  eye  diseases,  445 
cyclitis,  168,  445 
iritis,  158,  445 
Grafe's  operation  for  squint,  396 
Grafting,  390 
Granular  lids,  114 

opjithalmia.  114  I 

results,  119  I 

Granuloma  of  iris,  315 
Graves's  disease  (see  Goitre). 
Gummatous  sclerotitis,  166 

tarsitis,  307 
Gunshot  injuries,  183,  321  j 

Hard  cataract,  190 

Heart   disease,   eye  diseases  in, 

441 
Hemeralopia  (day -blindness),  276 
Hemianopia,  270,  451 
Hemorrhage     after     extraction. 
203 
choroidal,  179,  213,  218,  224, 

334 
conjunctival,  110 
in  h-itis,  153 
in  renal  retinitis,  231 
into  anterior  chamber,  153, 

180 
into  optic  nerve,  2-J3 

vitreous,  180,  282,  284 


Hemorrhage,  intra-ocular,  179 
orbital.  517 

retinal,  232,  241,  436,  441 
in  blood  diseases,  436 
secondarv,  after  iridectomy, 
414 
causing  glaucoma,  306 
Hereditary  amblyopia,  269 
disease  of  retina,  246 
gout,  eye  diseases,  445 
syphilis,  eye  diseases.  431 
Herpes  of  conjunctiva.  111 
of  cornea,  129 
zoster,  eye  diseases,  454 
Homatropine,  485 
Homonymous    diplopia    {see   Di- 
plopia). 
'  Hyalitis     {inflammation    of    vitre- 
\      oils  (see  Vitreous). 
I  Hydatid  of  orbit,  323 
I  Hydrocephalus,  eye  diseases,  450 
Hydrophthalmos,  149 
Hyperaesthesia  of  retina,  272 
Hypermetropia,  340 
acquired,  343 
axial,  340 
haze  of  disc.  229 
tests  for,  347 
Hyphfema    (blood    in   lower    part 

of  anterior  chamber),  153 
Hypopyon    (pus   in   lower  part  of 
anterior  chamber),  134,  153 
ulcer,  corneal  section,  406 
Hysterical  amblyopia,  272 

from  injurv  to  one  eye, 
272 
ocular  paralysis,  378 

ICE-BLIXDXESS,    275 

Idiopathic  phthisis  bulbi,  170 
Image  formed  by  lenses,  32 
retinal  size  of,  61 
I  E. 
39 
influence  of  lenses  on,  39 
Indirect  examination,  65,  69 
Infra-trochlear     nerve,     stretch- 
ing, 404 
Injuries  of  eyeball,  178 

of  orbit,  317 
Insufficiency,  muscular,  330 
Intra-ocular  tumor,  310 


500 


INDEX 


Intra-ocular      henioirhage      (see 

Hemorrhage). 
"  Inverted  image,"  65 
Iodoform    in    purulent   ophthal- 
mia, 108 
Iridectomy,  411 

distortion  of  image  after,  39 

exciting  glaucoma  in  other 
eye,  298 

in  cataract  extraction,  417 

in  corneal  opacity,  408 

in  corneal  ulcer,  139 

in  glaucoma,  299,  408 

in  iritis,  161 
Irideremia,  congenital,  162 
Irido-choroiditis,  168 

plastic,  159 
Irido  cyclitis,  170 

traumatic,  170 
Iridodesis,  410 

Iridoplegia     (paralysis    of    iris), 
376 

reflex,  376,  452 
Iridotomy,  410 
Iris,  absence  of,  162 

coloboma,  163 

color,  52,  153 

cysts,  315 

diffused  sarcoma  of,  315 

diseases,  152 

epithelial  tumor,  315 

granuloma,  315 

normal  action  of,  373 

operations,  408 

paralysis,  180,  377 

tremulous,  179 

tubercle,  315 

tumors,  315 

vessels  of,  154 

wounds  of,  184 
Iritis,  152 

after  extraction,  204 

atropine  in,  160 

causes  of,  158 

chronic,  159 

cold  in,  161 

gelatinous  exudation,  154 

glaucoma  secondary  to,  157, 
174 

gonorrhoeo-rheumatic,  444 

gouty,  159,  445 

heat  in,  160 


Iritis,  heredito-gouty,  159,  445 

hypopyon,  153 

in  corneal  ulcer,  132,  160 

in  diabetes,  440 

in  interstitial  keratitis,  146 

iridectomy,  161 

leeches  in,  161 

pain  in,  156 

paracentesis,  160 

plastic,  159,  174,  205 

pupil  in,  154 

recurrent,  158 

results,  156 

rheumatic,  158,  440 

serous,  156,  168 

suppurative,  153,  170,  203 

sympathetic,  173 

syphilitic,  158 

tension  in,  154 

traumatic,  162,  170 

treatment,  160 

with  nodules,  153,  158 
Iritomy,  410 

Irritation,  sympathetic,  173 
Ischcemia  retince,  244 
Ivory  exostosis,  322 

Jequirity,  486 
'  in  trachoma,  122 

Keratitis,  diffuse,  142 
interstitial,  142,  432 

iritis  in,  145 
marginal,  129,  144 
parenchymatous,  142 
punctata,  148,  168,  174 
secondary  forms,  147 
strumous,  129,  142 
syphilitic,  142,  430,  432 

Kerato-malacia,  141 

Keratoscopy,  82 

Kidney  disease,  eye  diseases  in, 
439 

Lachrymal  apparatus,  diseases, 
99 
canaliculi,  diseases,  100 
conjunctivitis,  102,  123 
gland,  diseases,  319 
abscess,  101,  319 
tumors  of,  324 
obstruction,  100 


INDEX. 


501 


436 


108  1 


Lachrymal  puncta,    alterations, 
99 
sac  diseases,  101,  393 

abscess,  101 
stricture,  100,  393 
treatment  of,  102 
Lachrymation,  99 
Lamellar  cataract,  197,  206 
treatment,  206 
and  convulsions,  454 
Lamina  crihrosa,  72,  257 
Lateral   sclerosis,   eye   diseases 

451 
Lead  opacity  of  cornea,  150 
poisoning,  eye  diseases 
Lebrun's  extraction,  419 
Leeches  in  iritis,  160 

in  purulent  ophthalmia 
Lens,  axes  of,  29 
concave,  29 
convex,  29 

crystalline,     changes     pre- 
ceding cataract,  191 
dislocation,  181,  208 
examination,  64 
mycpia  due  to  changes 

'in,  340 
senile  changes,  189 
definition,  28 
equator  of,  190 
foci  of,  31 

images  formed  by,  32 
refraction  by,  28 
refractive  power  of,  34 
signs    for  convex    and   con- 
cave, 41 
spherical  aberration,  30 
Lenses,  numeration  of,  40 
decentering  of,  36 
table  of  spectacle,  in  dioptres 
and  inches,  42 
Leprosy,  eye  disease  in,  446 
Leucocythgemia,  eye  diseases  iu, 

441 
Leucoma,  127 
Lice  on  eyelashes,  96 
Liebreich's     operation,     strabis- 
mus, 399 
Light,  effect  of  intense,  247 
Limeburn,  182 
Linear  extraction,  418 
Lippitudo,  92 


Locomotor     ataxv,     cycloplegia, 
451 
diplopia,  452 
iridoplegia,  376,  452 
optic  atrophy,  261,  451 
Lupus,  306 

conjunctival,  306 

Macula  lutea,  74,  227 

Magnet     for     removal    of     iron 

chips,  185 
Malarial  fever,  eye  diseases,  435 
Malignant  tumors  (see  Tumors). 
Malingering,  37,  277 
Marginal  keratitis,  129,  144 
Measles,  eye  diseases,  434 
Megalopsia,  276 
Megrim,  eye  symptoms,  447 
Meibomian  concretions,  95 

cyst,  94,  381 
Membranous    ophthalmia,    112, 

433 
Meningitis,  after  excision,  403 

epidemic  cerebro-spinal,  eye 
diseases,  435 

ocular  paralysis,  377 

optic  neuritis,  450 

recovery  with  optic  atrophy, 
450 

syphilitic,  449 

tubercular,  443,  450 

ulceration  of  cornea  in,  140 
Mercurial  teeth,  457 
Metastatic  growths,  312 
Micrococcus  of  trachoma,  117 

of  purulent  ophthalmia,  106 
Micropsia,  276 

Mobility    of    eye,    examination, 
56 
in  myopia,  56,  329 
Molluscum  contagiosum,  95 
Moon-blindness,  275 
Morgagnian  cataract,  199 
Mucocele,  101 

Muco-purulent  ophthalmia,  110 
Mules's  operation,  403 
Mumps,  eye  diseases,  434 
Mitscos  volitantes,  276,  330 
Muscular  asthenopia,  273,  330 
Mydriasis     (persistent     dilatation 
of  pupil),  paralytic,  379 

traumatic,  ISO 


502 


INDEX. 


Mydriatics,  action,  483 
Myopia,  327 

accommodation,  326 

axial,  328 

causes,  335 

clioroidal  changes,  226,  334 

complications,  330 

crescent,  221 

examination,  330 
Myopia  from  conical  cornea,  340 

from  incipient  cataract,  340 

of  curvature,  339 

retinal  images  in,  39,  329 

spectacles,  337 

strabismus  in,  329 

symptoms,  329 

tests  for,  330 

traumatic,  179 

treatment,  336 
Myosis    {perdstent    contraction    of 
pupil),  456 

in  spinal  disease,  452 

paralytic,  376 
Myotics,  action  of,  486 

N^vus  of  lids  and  conjunctiva, 

324 
Nasal  duct,  diseases  of,  100 

probing.  102,  393 
"  Near  point,"  49 
Nebula,  127 

Nerve,  facial,  paralysis,  455 
fifth,  paralysis,  455 
fourth,  paralysis,  370,  377 
optic,       inflammation      (see 
Neuritis). 

atrophy  (see  Atrophy), 
sixth,    paralysis,   369,   377, 

453 
sympathetic,  paralysis,  456 
third,  paralysis,  371,  453 
Nerve-fibres,  optic,  opaque,  228 
Neuralgia,  eye  symptoms,  4-18 
preceding     glaucoma,     298, 
448 
neuritis,  448 
Neuritis,  optic,  appearances,  250 
axial,  270 
descending,  248 
etiology,  255 
in  cerebral  tumor,  448 
in  cerebritis,  450 


I  Neuritis,   optic,   in    lead-poison- 
ing, 256 
in  meningitis,  450 
in  syphilitic  brain  dis- 
ease, 256,  449 
loss  of  blood  in,  256,  431 
pathology,  249 
pupils  in,  256 
retro-ocular,  256,  267 
sight  in,  254 
Neuro-retinitis,  254 
Neurotomy,  optico-ciliary,  402 
Night-bliiidness,  219 

functional,  275 
Nitrate  of  silver  in  corneal  ulcer, 
136 
in      ophthalmia,      108, 

110,  111 
staining       conjunctiva, 
151 
Nodal  point  of  eye,  38 
Nyctalopia  {night-blindness) ,  219 

endemic,  275 
Nystagmus,  380 

in  disseminated  sclerosis,  380 
miners',  380 

Objects,  apparent  size  of,  61 
Oblique  illumination,  63 
Occlusion  of  pupil,  155 
Ocular  paralysis,  causes,  377 

(see  also  Paralysis). 
Onyx, 134 

Opaque  optic  nerve-fibres,  228 
Operation    for   abscess  of  orbit, 
318 
for  abscission  of  eye,  402 
for  artificial  pupil,  408 
for  canthoplasty,  390 
for  cataract,  200,  415 

causes  of  failure,  203 
extraction,  413 
modified  linear,  418 
needling,  424 
old  flap,  419 
short  flap,  419 
simple  linear,  418 
solution,  424 
suction,  426 
for  conical  cornea,  407 
for  distended  frontal  sinus, 
322 


INDEX. 


503 


Operation  for  division  of  canthus, 
136 
for  ectropion,  388 
for  entropion,  organic,  383 

spasmodic,  382 
for  epilation,  381 
for  eversion  of  eyelids,  381 
for  evisceration  of  eyeball, 

403 
for  excision  of  eye,  401 
for  foreign  body  on  cornea, 

404 
for  inspection  of   cornea  in 

pbotopliobia,  382 
for  iridectomy,  411 
for  iridodesis,  410 
for  iridotomy  410 
for  lachrymal  abscess,  101 

stricture,  393 
for  Meibomian  cyst,  381 
for  paracentesis  of  anterior 

chamber,  405 
for  peritomy,  391 
for  ptosis,  390 
for  readjustment,  399 
for  sclerotomy,  414 
for  slitting  canaliculus,  392 
for  strabismus,  395,  400 
for    stretching     infra-troch- 
lear  nerve,  404  ! 

for  symblepharon,  391 
for  trichiasis,  383 
Operations,  381 

lachrymal,  392 
on  cornea,  404 
on  eyelids,  381 
on  iris,  408 
Ophthalmia,  105 

after  exanthems,  111 
catarrhal,  110 
chronic,  122 
croupous,  112 
diphtheritic,  112,  433 
follicular,  116 
from  atropine,  124 
from  cold,  112 
from  drugs,  124 
from  eserine,  124 
from  irritants,  112 
gonorrhoea],  105 
granular,  114 

results  of.  119 


Ophthalmia,     granular,      treat- 
ment of,  118 
impetiginous,  112 
in  eczema,  112 
in  erysipelas,  112 
in  herpes  zoster,  112,  454 
marginal,  131 
membranous,  112,  433 
mucopurulent,  110 
neonatorum,  105 

prevention  of,  110 
palpebral,  125 
phlyctenular,  129 
purulent,  105 

treatment  of,  108 
pustular,  129 
rheumatic,  112,  443 
strumous,  129 
tarsi,   91 
Ophthalmitis,  sympathetic,  173 
Opht/ialmo/jlegia       externa,       372, 
421 
interna,  377 
Ophthalmoscope,  488 
how  to  use,  67 
refraction,  80 
Ophthalmoscopic      examination, 
65 
direct  method,  66,  77 

in  myopia,  77 
indirect  method,  65,  69 
Optic  disc,  atrophy,  257,  451 
congestion,  250 
healthy,  71 
physiological  cup,  72 
variations    in    color   of, 
72 
nerve,  diseases  of,  249   (see 
also  Neuritis  and  Atrophy) . 
from  syphilis,  256, 
431 
injury  to,  262 
pathological      changes, 

248 
sclerosis,  258 
sheath  of,  249 
tumors,  324 
papilla,  71 
Optical  outlines,  25 
Optico-ciliary  neurotomy,  402 
Orbicularis,  paralysis,  99,  456 
spasm,  128 


504 


INDEX 


Orbit,  abscess  of,  318 

cellulitis  of,  318 

diseases  of,  317 

emphysema  of,  317 

foreign  body  in,  320 

pulsaiing  tumors  of,  322         ' 

tumors,  317,  321 

wounds  of,  320 
Oscillation  of  pupil,  51,  173 

P  A  N  N  u  s     (extensive     superficial  \ 
vascularity  of  cornea),  V20    \ 
phlyctenular,  131 
trachomatous,  Hi) 
Panophthalmitis,  170 
purulent,  170 
pyaemic,  436 
traumatic,  170,  184 
Papillitis     {inflammation    of   optic 

disc  {see  Neuritis). 
Papillo-retinitis,   238,  255 
Paracentesis    of   anterior    cham- 
ber, 405 
for  corneal  ulcer,  138 
for  glaucoma,  300 
for  iritis,  160 
Parallactic  movement 
Paralysis,  associated, 
central,  453 
diphtheritic,  433 
in  spinal  disease, 
ocular,  377,  451 
causes,  377 
treatment,  379 
of      cervical       sympathetic 

nerve,  456 
of  ciliary  muscle,  180,  377. 

433 
of  external  ocular  muscles, 
372 
of  rectus   (6th  N.),  369 
of  facial  nerve,  455 
of  fifth  nerve,  455 
of  internal  ocular   muscles, 

180,  377 
of  iris,  180,  377 
of  superior  oblique  (4th  N.), 

370, 377 
of  third  nerve,  371 
peripheral,  450 
syphilitic,  430,  432,  453 
Paralytic  myosis,  376 


236 
453 


452 


Paralytic  mydriasis,  377 
Pediculus  pubis,  96 
"Pemphigus"    of     conjunctiva, 

125 
Perforating    conjunctival    ulcer, 

130 
Perimeter,  45,  490 
Periostitis  of  orbit,   318 
Peritomy,  122,  391 
Phlyctenular  affections,  111,  129 

pannus,  131 
Photopho])ia,  128,  136 
Phthisis  bulbi,  idiopathic,  170 
Physiological  cup,  72 
Physiology  of   internal   muscles 

of  eye,  373 
Pigment  in  retina,  233,  244 

in  choroid,  215,  219,  245 
Pilocarpine  for  detached  retina, 

236 
Pinguecula,  308 
Pohjopia  unioodaris,  195 
Polypus  lachrymal,  101 
Posterior  nodal  point,  38 

polar  cataract,  193,  197 

staphyloma,  221,  334 

synechia,  152 
total,  155 
Preliminary  iridectomy,  417 
Presbyopia,  359 

in  myopia,  361 

table,  362 
Primary  optic  atrophy,  257,  419 
Prisms,  action  of,  27,  35 

numbering  of,  42 

uses  of,  35,  339 
Prismatic  spectacles,  339 
Probing  nasal  duct,  393 
Progressive  optic  atrophy,   258, 

451 
Projection,  28 
Prolapse  of  iris,  205 

in   cataract    extraction, 

205,  423 
in  sclerotomy,  300.  415 
Proptosis,  62,  321 

in  orbital  disease,  322 
Protective  glasses,  487 
Pseudo-glioma,  311,  435 
Pterygium,  308 

Ptosis     (falling    of    upper    Jid), 
congenital,  98 


INDEX. 


605 


Ptosis  from  granular  lids,  122 

operations,  390 

paralytic,  371 

traumatic,  318 
Pulsating  tumor  of  orbit,  322 
Pulsation,  retinal,  in  aortic  dis- 
ease, 441 
Punctum,  displacement  of,  99 
Pupil  (see  also  Iris,  Synechia). 

actions,  in  health,  50 

contraction  from  congestion, 
51 

examination,  50 

exclusion,  155 

inactivity  of,  51 

in   diphtheritic  cycloplegia, 
433 

influence  on  sight,  40 

in  head  injuries,  449 

in  iritis,  154 

in  optic  atrophy,  260 

in  neuritis,  2.:)7 

in  spinal  disease,  452 

occlusion  of,  155 

size  of,  in  anaemia,  52  j 

total    post,    synechia,    155, 
304 

why  black,  65 
Pupillary    membrane,     remains 

of,  163 
Pupilloscopy,  82 
Purpura,  eye  disease,  435 
Pustular  ophthalmia,  129 
Pyaemia,  eye  disease,  436 

Quinine  amblyopia,  439 

lotion  in   diphtheritic   oph- 
thalmia, 114 

"Rainbows"    in  glaucoma,  287 
Readjustment    of    ocular    mus- 
cles, 399 
Recurrent  vascular  ulcer,  131 
Reflex  iridoplegia,  376,  452 
Refraction,  25 

by  a  prism,  27 
by  a  cylindrical  lens,  350 
determination    by   ophthal- 
moscope, 78 
by  retinoscopy,  82 
errors,  326 
of  light,  25 


Refraction  of  the  eye,  37 

Refractive  index,  25 

Relapsing    fever,    eye    diseases, 

435 
Relative  accommodation,  50 
Renal  disease,  eye  diseases,  439 
Retina,  anaesthesia,  272 

appearances  in  disease,  229 

in  health,  73,  226 
atrophy,  233 
bloodvessels,  74,  226 
concussion,  181 
congestion,  229 
detachment,  179,  234,  335 
diseases,  226 
functional  diseases,  275 
glioma,  226,  310 
hemorrhage  in,  232 
hyperaesthesia,  272 
pigmentation,  232,  244 
"shot-silk"  appearance,  228 
tubercle,  226 
vessels  of,  74 
white  patches,  231,  238 
Retinal  embolism,  242,  442 
hemorrhage,  241,  436,  441 
in   blood  diseases,  436, 
441 
image,  38,  39 

in  myopia,  39 
influence   of   lenses   on 

size,  39 
thrombosis,  242,  442 
Retinitis,  albuminuric,  230,  238, 
439 
renal  disease  in,  240 
upoplectica,  241 
difiused,  229 
hoemorrhagica,  241,  445 
from  anaemia,  441 
from  intense  light,  247 
from  lead,  436 
from  leucocythaemia,  441 
from  malarial  disease,  435 
pigmentosa,  233,  244 
renal  {see  Albuminuric), 
syphilitic,  236,  430 
with   choroiditis,  210,    214, 

233 
with  optic  neuritis,  238,  254 
Retinoscopy,  82 
Rheumatism,  eye  diseases,  443 


22 


506 


1  NDEX. 


Rheumatism,  in  ophthalmia  neo- 
natorum, 445 
Ring-scotoma,  238 
Ripening  cataract,  operation,  202 
Rodent  ulcer,  96 
Rotation  of  eye,  centre  of,  39 
Rupture  of  choroid,  179,  217 
of  eyeball,  178 

Saemisch's  operation,  138 
Sago-grain  granulations,  115 
Salmon-patch,  143 
Sarcoma  of  choroid,  312 

of  ciliary  body,  312 

of  front  of  the  eye,  310 

of  iris,  315 

of  sclerotic,  310 
Scalds  of  eye,  182 
Scarlet   fever,  eye   disease,   113, 

432 
Scarring  of  conjunctiva,  119 
Scleral  ring,  71 
Scleritis,  164 

gummatous,  166 
Sclero-iritis,  166 
Sclero-keratitis,  166 
Sclerosis   of    optic  nerves,    258, 

261 
Sclerotic  rupture,  178 

wounds,  186 
Sclerotico-choroiditis,     posterior, 

221 
Sclerotitis,  scrofulous,  166 
Sclerotomy,  300,  414 
Scotoma    {an   area     of    defect    or 
blindness  in  the  visual  field) , 
268 

central,  268 

flittering,  447 
Scrofulous  eye  diseases,  446 

sclerotitis,   166 
Scurvy,  eye  disease,  436 
Secondary  cataract,  194 

divergence,  369 

glaucoma,  286,  304 

keratitis,  147 

operations  for  cataract,  423 

squint,   57 
Senile  changes    in    accommoda- 
tion, 361 
in  choroid,  222 
in  lens,  189 


Senile  failure  of  vision,  48 
Septicaemia,  eye  diseases,  436 
Serous  iritis,  156,  168 
Serpiginous  ulcer,  132 
Setons    in    svphilitic    keratitis, 
146 
in  ulcers  of  cornea,  137 
Shades,  487 
Shadow-test,  82 
Short  sight,  327 
Sight,  acuteness,  48 
tests  for,  48 
after     cataract     operations, 

199,  206 
field,  44 

for  colors,  279 
in  optic  atropy,  258 

neuritis,  253 
optical    conditions  of   clear, 
39 
Silver-staining    of    conjunctiva, 

151 
Sloughing  of  cornea,  107 
Smallpox,  eye  disease,  432 
Snellen's  operations  for   trichia- 
sis, 386 
Snow-blindness,  275 
Soft  cataract,  191 
Solution  of  cataract,  200 
Sparkling  synchysis,  283 
Spasm  of  accommodation,  330 
Spectacles  in  astigmatism,  357 
in  anisometropia,  358 
in  hj'permetropia,  347 
in  myopia,  336 
in  presbyopia,  361 
lenses,  table  of,  42 
prismatic,  339 
Spinal  cord  disease,  eye  diseases, 

451 
Spongy  exudation  in  iritis,  154 
Spring  catarrh,  123,  131 
Squint  {see  Strabismus). 
Staphyloma     (a     bulging    of    the 
sclerotic  or  cornea),  167 
anterior,  167 
posterior,  221,  334 
Stillicidium  lacrimarum,  99 
j  Stomatitic  teeth,  457 
j  Strabismus,  alternating,  57,  345 
I  angular  measurement  of,  59 

apparent  (footnote),  58 


INDEX 


507 


Strabismus,  causes,  366 
concomitant,  58,  345 
convergent,  58,  344,  364 
definition  and  varieties,  57, 

363 
divergent,  57,  365 
examination,  57 
from  disuse,  368 
in  hyi3ermetropia,  344 
in  myopia,  329,  367 
latent  divergent,  367 
measurement  of,  58 
operation  for,  395 
paralytic,  58,  368,  372 
peculiarities  of,  372 
periodic,  58,  345 
primary,  58 
secondary,  58 

spontaneous    disappearance 
of,  265,  349 
Streatfeild's    operation    for    tri- 
chiasis, 386 
Strise  of  refraction,  191 
Strumous  eye  diseases,  446 

oplithalmia,  129 
Stye,  93 

Suction  of  cataract,  201 
Suppression  of  image,  264 
Suppuration     after     extraction, 

2U3 
Sycosis  tarsi.  91 
Symblepharon,  182,  391 
Sympathetic   inflammation,  171, 
173 
irritation,  171,  173 
nerve,  paralysis  of,  456 
ophthalmitis,  174 
theories  of,  171 
treatment  of,  175 
Synchysis,  sparkling,  283 
Syndectomy,  122 
Synechia   (adhesion  of  iris),   an- 
terior, 184 
causing  glaucoma,  157 
posterior,  152 
total  posterior,  155,  304 
Syphilis,    acquired,    choroiditis, 
430 
eye  diseases,  429 
iritis,  429 
keratitis,  246,  430 
ocular  paralysis,  430 


!  Syphilis,  acquired,  retinitis,  430 
]  brain  disease,  256,  431 

I  inherited,  choroiditis,  432 

eye  diseases,  431 
iritis,  431 
keratitis,  141,  432 
ocular  paralysis,  63 
retinitis,  432 
orbital  disease,  321 
sclerotitis,  166 
tarsitis,  308 
ulcers  of  eyelids,  97 
Syphilitic,  optic  atrophy,  431 
neuritis,  431 
teeth,  457 
Syringes,  for  cataract  suction, 426 
lachrymal,  394 

Tarsitis,  syphilitic,"  308 
Teeth  in  lamellar  cataract,  459 

syphilitic,  146,  457 
Tenotomy,  395 

Tension  of  the  eyeball,  examina- 
tion, 43 
diminished,  170 
increased,  286 
in  glaucoma,  286,  288, 

293 
in  intra-ocular  tumors, 

298,  311 
in  iritis,  154 
in  paralysis  of  the  fifth 

nerve,  298 
variation,  44 
Test-types,  48,  488 
Third-nerve  paralysis,  371 
Thrombosis  of  cavernous   sinus, 
319 
of  retinal  artery,  242,  442 
vein,  241 
Tinea  tarsi,  91 

Tobacco  amblyopia,  269,  437 
Total    posterior    synechia,    155, 

304 
Toxic  amblyopia,  269 
Trachoma,  114 

coccus  of,  115,  117 
Traumatic  astigmatism,  181 
cataract,  207 
cycloplegia,  180 
irido-cyclitis,  159,  170 
iridoplegia,  180 


508 


I  N  D  f;  X 


Traumatic  iritis,  159 

myopia,  181 

panophthalmitis,  170,  184     \ 

ptosis,  318 
Trichiasis,  120 

Tubercle   of  choroid,    216,    222 
442 

of  iris,  315  ! 

Tuberculosis,  eye  diseases,  442     , 
Tumors,  intra-ocular,  310  j 

malignant,  309  i 

of  eye,  307 

of  eyelids,  307 

of  front  of  eyeball,  307 

of  orbit,  321 
Typhus  fever,  eye  disease,  432 

Ulcers  of  cornea  (see  Cornea), 
of  lids,  lupous,  97 
rodent,  96 
syphilitic,  97 
Undiscovered    blindness   of    one 

eye,  266 
Unequal    refraction    of   the   two 

eyes,  358 
Uraemic  amaurosis,  433 

V   Y    OPERATION    for    ectropion, 
389 

Van    Millingen's    operation    for 
trichiasis,  387 

Vense  vorticosae,  211 

Vessels  of  anterior  part  of  eye- 
ball, 52 

Virtual  image,  size,  32 

Vision  (see  Sight). 

field  of  (see  Field  and  Sight). 

Visual  angle,  38 


Visual  axis,  39,  48 
Vitreous,  diseases  of,  281 

dust-like  opacities,  281 

examination,  77,  282 

liemorrhage,  284 

in  choroiditis,  219,  285 
traumatic,  284 

humor,  cholesterin  in,  283 
in  glaucoma,  294 
inirido-eyclitis,  168,  285 
in  myopia,  284,  335 
in  retinitis,  285 

opacities,  281 

parasites  in,  284 

Warts,  95 

conjunctival,  307 
"Watered-silk"  appearance    of 

retina,  228 
Watery  eye,  99 
Waxy  disc,  219,  245 
Whooping-cough,     eye    disease, 

434 
Woolly  disc,  253 
Wounds  of  eyeball,  181,  183 

rules    as   to   treatment, 
184,  186 
Wounds  of  eyelids,  320 
of  orbit,  320 

Xanthelasma  palpebrarum,  95 
Xerosis  of  conjunctiva,  125 

Yellow  spot,  74 

Zone,  dangerous,  172 

Zonular  cataract  (see  Lamellar). 


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This  List,  which  is  by  far  the  most  handsome  and  convenient  now  attainable, 
has  been  thoroughly  revised  for  1893.  A  full  description  will  be  found  on  page  16. 
It  is  issued  in  four  styles.  Price,  each,  Sl.2o.  Thumb-letter  Index  for  quick  use  25 
cents  extra.  For  Special  Combination  Rates  with  periodicals  and  the  Year-Book 
of  Treatment  see  above. 
(3.1.3.) 


2  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

ABBOTT  (A.  C).  PRINCIPLES  OF  BACTERIOLOGY:  a  Practical 
Manual  for  Students  and  Physicians.  In  one  l2mo.  volume  of  259 
pages,  with  32  illustrations.  Cloth,  $2. 
ALLEN  (HARRISON).  A  SYSTEM  OF  HUMAN  ANATOMY. 
^  WITH  AN  INTRODUCTORY  SECTION  ON  HISTOLOGY,  by 
E.  O.Shakespeare,  M.D.  Comprising  813  double-columned  quarto 
pages,  with  380  engravings  on  stone  on  109  plates,  and  241 
woodcuts  in  the  text.  In  six  sections,  each  in  a  portfolio.  Price 
per  section,  $3  60.  Also,  bound  in  one  volume,  cloth,  $23;  half 
Russia,  $25.     Sold  by  subscription  only . 

AMERICAN    SYSTEM    OF    DENTISTRY.      In    treatises   by   various 
"^    authors.     Edited  by  Wilbur  F.  Litch,  M.D..  D.D.S.      In  three  very 
handsome  super-royal   octavo  volumes,  containing  3180  pages,  with 
2863  illustrations  and  9  full-page  plates.     Noiv  ready ■     Per  volume, 
cloth,  $6  ;    leather,  $7  ;  half  Morocco,  $8.     For  sale  by  subscription 
only.     Apply  to  the  publishers. 
AMERICAN  SYSTEMS  OF  GYNECOLOGY  AND  OBSTETRICS.     In 
•^    treatises  by  the  most  eminent   American  speciulists.     Gynecology 
edited  by  Matthew  D.  Mann,  A  M.,  M.D.,  and  Obstetrics  edited  by 
Barton  C.  Hirst,  M.D.     In   four  large  octavo  volumes   comprising 
3612  pages,  with  1092  engravings,  and  8  colored  plates.    Per  volume, 
cloth,  $5  ;    leather,   $6  ;   half  Russia,    $7.      For  sale  by  subscription 
only.    Prospectus  free  on  application  to  publishers. 
A  SHHURST  (JOHN,  Jr.)     THE  PRINCIPLES  AND  PRACTICE  OF 
•^    SURGERY.     FOR  THE    USE  OF   STUDENTS   AND  PRACTI- 
TIONERS.    Fifth  and  revised  edition.     In  one  large  and  hand- 
some octavo  volume  of  1144  pages,  with  642  woodcuts  Cloth,  $6; 
leather,  $7, 

ASHWELL  (SAMUEL) .  A  PRACTICAL  TREATISE  ON  THE  DIS- 
EASES  OF  WOMEN.     Third  edition.     520  pages.     Cloth,  $3  50. 

A  SYSTEM  OF  PRACTICAL  MEDICINE  BY  AMERICAN  AUTHORS. 
Edited  by  William  Pepper,  M.D.,  LL.D.  In  five  large  octavo 
volumes,  containing  5573  pages  and  198  illustrations.  Price  per 
volume,  cloth,  $5  00;  leather,  $6  00;  half  Russia.  $7  00.  Sold  by 
subscription  only.     Address  the  publishers. 

ATTFIELD  (JOHN).  CHEMISTRY  ;  GENERAL,  MEDICAL  AND 
PHARMACEUTICAL.  Twelfth  edition,  specially  revised  by  the 
Author  for  America.  In  one  handsome  12mo.  volume  of  782 
pages,  with  88  illustrations.     Cloth,  $2  75  ;  leather,  $3  25. 

BALL  (CHARLES  B.)  DISEASES  OF  THE  RECTUM  AND  ANUS. 
In  one  12mo.  vol.  of  417  pages,  with  54  ilius.  and  4  colored  plates. 
Cloth,  $2  25.      See  Series  of  Clinical  Mafiuals,  p.  13. 

BARLOW    (GEORGE    H.)     A   MANUAL  OF  THE  PRACTICE   OF 
MEDICINE.     In  one  8vo.  volume  of  603  pages.     Cloth,  $2  50. 
BARNES    (ROBERT).     A  PRACTICAL  TREATISE  ON   THE  DIS- 
EASES  OF  WOMEN.    Third  American  from  3d  English  edition.  In 
one  8vo.  vol.  of  about  800  pages,  with  about  200  illus.    Preparing. 

BARNES  (ROBERT  and  FANCOURT).  A  SYSTEM  OF  OBSTET- 
RIC MEDICINE  AND  SURGERY,  THEORETICAL  AND  CLIN- 
ICAL. The  Section  on  Embryology  by  Prof.  Milnes  Marshall 
In  one  large  octavo  volume  of  872  pages,  with  231  illustrations. 
Cloth,  $5;  leather,  $6. 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 


DARTHOLOW  (ROBERTS).  CHOLERA;  ITS  CAUSATION,  PRR- 
VENTIOXANDTREATMEXT.    In  one  12rao.  volume.   Preparing. 

MEDICAL    ELECTRICIUY.      A     PRACTICAL    TREATISE 

ON  THE  APPLICATIONS  OF  ELECTRICirY  TO  MEDICINE 
AND  SURGERY.  Third  edition.  In  one  8vo  vol.  of  308  pages, 
with  110  illustrations.     Cloth,  S2  50. 

DASHAM  (W.  R.)     RENAL  DISEASES;   A  CLINICAL  GUIDE  TO 

^  THEIRDIAGNOSIS  AND  TREATMENT.  In  one  12m  volume 
of  304  pages,  with  illustrations.     Cloth,  $2  00 

•pELL  (F.  JtFFKEY).  COMPARATIVE  ANATOMY  AND  PHY- 
SIOLOGY.  In  one  12rao.  volume  of  561  pages,  wirh  229  woodcuts 
Cloth,  $2.     See  Students'  Series  of  Manuals,  p.  14. 

-pELLAMY  (EDWARD).  A  MANUAL  OF  SURGICAL  ANATOMY. 
In  one  ]2ino.vol.  of  300  p  iges,  with  50  illustrations.  Cloth,  $2  25. 

BERRY  (GEORGE  A.)  DISEASES  OF  THE  EYE;  A  PRACTICAL 
TREATISE  FOR  STUDENTS  OF  OPHTHALMOLOGY.  New  (2.1) 
edition.  Very  handsome  octavo  vol.,  about  700  pages,  with  about 
150  original  illustrations  in  the  text,  of  which  62  are  exquisitely 
colored.     Ih  press. 

■piLLINGS  (JOHN  S.)     THE  NATIONAL  MEDICAL  DICTIONARY. 

•L>  Including  in  one  alphabet  English,  French,  German,  Italian,  and 
Latin  Technical  Terms  used  in  Medicine  and  the  Collateral  Sciences. 
In  two  very  handsome  imperial  octavo  volumes,  containing  1574 
pages  and  two  colored  plates.  Per  volume,  cloth,  $6  ;  leather,  S7  ; 
half  xVIorocco,  $8  50.  For  sale  by  subscription  only.  Specimen 
pages  on  application  to  publishers. 

"DLOXAM    (C.  L.)     CHEMISTRY,   INORGANIC    AND   ORGANIC. 

-D  With  Experiments.  New  American  from  the  fifth  London  edition. 
In  one  handsome  octavo  volume  of  727  pages,  with  292  illustra- 
tions. Cloth,  $2;  leather,  $3. 
BEISTOWE  (J.  S.)  A  TREATISE  ON  THE  SCIENCE  AND  PRAC- 
TICE OF  MEDICIXE  Seventh  edition.  Large  octavo  volume, 
1325  page.?,  114  illustrations.     C.oth,  §6.50  ;  leather,  S7  50. 

■pROADBENT  (W.  H).     THE  PULSE.     In  one  12mo.  volume  of  317 

■D  pages,  with  59  engravings.  Cloth,  $1  75.  See  Series  of  Clinical 
Manuals,  p.  13. 

BROWNE  (LENNOX).  A  PRACTICAL  GUIDE  TO  DISEASES  OF 
THE  THROAT  AND  NOSE,  including  Associated  AfiFections  of 
the  Eur.  New  ,4th)  and  enlarged  edition.  In  one  imperial  octavo 
volume  of  about  750  pages,  with  235  engravings  and  12U  illustrations 
in  color.     Preparing. 

KOCH^S  REMEDY  IN  RELATION  ESPECIALLY  TO  THROAT 

CONSUMPTION.    In  one  octavo  volume  of  121  pages,  with  45  illus- 
trations,  4  of  which  are  colored,  and  17  charts,  Oloth,  $1   50. 
BRUCE    (J.    MITCHELL).      MATERIA    MEDICA    AND    THERA- 
PEUTICS.   New  (fifth)  edition.    In  one  l2mo.  volume  of  about  600 
pages.     Cloth,  $1  50.      See  Students''  Series  of  Mamials,  p.  14. 

BRUNTON  (T.  LAUDER).  A  MANUAL  OF  PHARMACOLOGY, 
THERAPEUTICS  AND  MATERIA  MEDICA;  including  the 
Pharmacy,  the  Physiological  Action  and  the  Therapeutical  Uses  of 
Drugs.  Third  and  revised  edition,  in  one  octavo  volume  of  1305 
pages,  with  230  illustrations.     Cloth,  $5  50;  leather,  $6  50. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth 
American  from  the  fourth  English  edition.  In  one  imperial  octavo 
volume  of  1040  pages,  with  727  illustrations.  Cloth,  $6  50; 
leather,  §7  50. 

BUMSTEAD  (F.J.)  and  TAYLOR  (R  W.)  THE  PATHOLOGY  AND 
TREATMENT  OF  VENEREAL  DISEASES.  New  edition.  See 
Taylor  on  Venereal  Diseases. 


4  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

■pURNETT  (CHARLES  H.)    THF  EAR:   ITo  ANATOMY,  PHYSI 
^     OLOOY  AND  DISEASES.      A  Practical  Treatise  for  the  Use  of 

Student."  and  Practitioners.     Second  edition.     In  one  8vo.  vol    of 

580  pp.,  with  107  illus.     Cloth.  84  ;  leather,  $5. 
■pUTLIN,  (HENRY  T.)      DISEASES   OF    THE    TONGUE.      In  one 

pocket-size  ]2mo.  vol.  of  456  pp.,  with  8  col.  plates  and  .3  woodcuts. 

Limp  cloth,  $.3  50.      See  Series  of  Clinical  Mannrils,  p.  13. 
pARPENTER  (WM.  B  )     PRIZE  ESSAY  ON  THE  USE  OF  ALCO- 
^     HOLIC  LIQUORS  IN  HEALTH  AND  DISEASE.     New  Edition, 

with  a  Preface  by  D.  F.  Condie,  M.D.     One  12mo.  volume  of  178 

pages.    Cloth,  60  cents. 
PRINCIPLES  OF  HUMAN  PHYSIOLOGY.     A  new  American, 


from  the  eighth  English  edition.     In  one  large  8vo.  volume. 
riARTER  (R.  BRUDENELL)  AND  FROST  (W.  ADAMS)     OPHTHAL- 

MIC  SURGERY.     In  one  pocket-size  12mo.  volume  of  559  pages, 

with  91   engravings  and  one  plate.     Cloth,    .$2  25.     See  Series    of 

Clinical  Manuals,  p.  13. 
CHAMBERS  (T.  K.)      A  MANUAL  OF  DIET  IN  HEALTH   AND 
^     DISEASE.    In  one  handsome  8vo.  vol.  of  302  pnges.    Cloth,  $2  75. 
pHAPMAN  (HENRY  C  ).   A  TREATISE  ON  HUMAN  PHYSIOLOGY. 

In  one  octavo  volume  of  925  pages,   with  605  illustrations.     Cloth, 

$5  50  ;  leather,  $6  50. 

CHARLES    (T.    CRANSTOUN).      THE    ELEMENTS    OF    PHYSIO- 
LOGICAL AND  PATHOLOGICAL  CHEMISTRY.     In  one  hand- 
some octavo  volume  of  451  pages,  with  38  woodcuts  and  one  colored 
plate.    Cloth,  3  50. 
pHTJRCHILL    (FLEETWOOD).     ESSAYS   ON    THE    PUERPERAL 
^     FEVER.    In  one  octavo  volume  of  464  pages.     Cloth,  $2  50. 
pLARKE  (W.  B.)   AND  LOCKWOOD   (C.  B.)      THE  DISSECTORS 
MANUAL.    In  one  12mo.  volume  of  396  pages,  with  49  illustrations. 
Cloth,  $1  50.      See  Students'  Series  of  Manuals,  p.  14. 
pLASSEN'S  QUANTITATIVE  ANALYSIS.    Translated  by  Edgar  F. 
^     Smith,  Ph.D.  In  one  12mo.  vol.  of  324  pp.,  with  36  illus.  Cloth.  $2  00. 
pLELAND  (JOHN).     A  DIRECTORY  FOR  THE  DISSECTION  OF 
^     THE  HUMAN  BODY.    In  one  12mo.  vol.  of  178  pp.    Cloth,  $125. 
pLOUSTON  (THOMAS  S.)      CLINICAL   LECTURES    ON    MENTAL 
^     DISEASES.    With  an  Abstract  of  Laws  of  U.  S.  on  Custody  of  the 
Insane,  by  C.  F.  Folsom,  M.D.     In  one  hatdsome  octavo  vol.  of  541 
pages,  illustrated  with  woodcuts  and  8  lithographic  plates.      Cloth, 
$4  00.     Dr.   Folsom's  Abstract  is  also  furnished  separately  in  one 
octavo  volume  of  108  pages.     Cloth,  $1   50. 
p LOWES  (FR.\NK).    AN  ELEMENTARY  TREATISE  ON  PRACTI- 
^     CAL  CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALY- 
SIS.    New  American  from  the  fourth  English  edition.    In  one  hand- 
some 12mo,  volume  of  387  pages,  with  55  illustrations.    Cloth,  $2  50. 
COATS  (JOSEPH).    A  TREATISE  ON  PATHOLOGY.     In  one  vol.  of 
829  pp.,  with  339  engravings.      Cloth,  $5  50;  leather,  $6  50 
COHEN  (3.  SOLIS).    A  HANDBOOK  OF  APPLIED  THERAPEUTICS. 
one  large  12mo.  volume,  with  illustrations.      Prep'iring 
COLEMAN  (ALFRED).    A  MANUAL  OF  DENTAL  SURGERY  AND 
PATHOLOGY.     With  Notes  and  Additions  to  adapt  it  to  American 
Practice.   By  Thos.  C.  Stellwagen,  M.A.,  M.  D.,  D.D.S.  In  one  hand- 
some 8vo.  vol.  of  412  pp.,  with  331  illus.    Cloth,  $3  25. 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS.  5 

fjONDIE  (D.FRANCIS).    A  PRACTICAL  TREATISE  ON  THE  DIS- 
^     EASES  OF  CHILDREN.    Sixth  edition,  revised  and  enlarged.    In 

one  large  8vo.  vol.  of  719  pages.     Cloth,  $5  25  ;  leather,  £6  25. 
naRNIL  (V.)    SYPHILIS:  ITS    MORBID  ANATOMY,  DIAGNOSIS 
^     AND  TREATMENT.     Translated,  with  notes  and  additions,  by  J. 

Henry  C.   Simes,  M.D  ,  and  J.  William  White,  M.D.    In  one  8vo. 

volume  of  461  pages,  with  84  illustrations.     Cloth,  $.3  75. 
nULVER  (E.  M.)  AND  HAYDEN  (J.  R.)    MANUAL  OF  VENEREAL 
^     DISEASES.     In  one  12mo.  vol.  of  289  pages,  with  33  illustrations 

Cloth.  $1  75. 

rjALTON  (JOHN  C.)  A  TREATISE  ON  HUMAN  PHYSIOLOGY. 
Seventh  edition  thoroughly  revised,  and  greatly  improved.  In  one 
very  handsome  8vo.  vol.  of  722  pages,  with  252  illustrations. 
Cloth,  $5  ;   leather,  $6. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.    In 

one  handsome  12mo.  vol.  of  293  pp.     Cloth,  .$2. 

riANA  (JAMES  D.)    THE  STRUCTURE  AND  CLASSIFICATION  OF 

-^     ZOOPHYTES.   Withillust.onwood.  In  one  imp.  4to.  vol.   CI.,  $4. 

TiAVENPGRT  (F.  H.)  DISEASES  OF  WOMEN.  A  Manual  of  Non- 
Surgical  Gyngecology.  For  the  use  of  Students  and  General  Prac- 
titioners New  (second)  edition.  In  one  handsome  12mo.  volume 
of  314  pages  with  107  illustrations.     Cloth,  $1  75. 

TJAVIS  (F.H.)  LECTURES  ON  CLINICAL  MEDICINE.  Second 
edition     In  one  12mo.  volume  of  287  pages.     Cloth,  $1  75. 

TjELABECHE'S  GEOLOGICAL  OBSERVER.  Inone  largeSvo.  vol. 

^    of  700  pages,  with  SOOillustrations.    Cloth,  $4. 

TJRAPER  (JOHN  C.)  MEDICAL  PHYSICS.  A  Text-book  for  Stu- 
dents and  Practitioners  of  Medicine.  In  one  handsome  octavo  vol- 
ume of  734  pages,  with  376  illustrations.     Cloth,  $4. 

TJRTJITT    (ROBERT).     THE   PRINCIPLES   AND  PRACTICE    OF 

■^  MODERN  SURGERY.  A  new  American  from  the  12th  London 
edition,  edited  by  Stanley  Boyd,  F.R.C.S.  In  one  large  octavo 
volume  of  965  pages,  with  373  illustrations.    Cloth,  $4  ;  leather,  $5. 

TjTJNCAN  (J.  MATTHEWS).    CLINICAL  LECTURES  ON  THE  DIS- 

■^  EASES  OF  WOMEN.  Delivered  in  St.  Bartholomew's  Hospital. 
In  one  octavo  volume  of  175  pages.    Cloth,  $1  50. 

■nTJNGLISON  (ROBLEY),  MEDICAL  LEXICON;  A  Dictionary  of 
Medical  Science.  Containing  a  concise  explanation  of  the  various 
subjects  and  terms  of  Anatomy,  Physiology,  Pathology,  Hygiene, 
Therapeutics,  Pharmacology,  Pharmacy,  Surgery,  Obstetrics,  Medi- 
calJurisprudenceand  Dentistry  ;  notices  of  Climate  and  of  Mineral 
Waters  ;  Formulae  forOfficinaL  Empirical  and  Dietetic  Preparations; 
with  the  accentuation  and  Etymology  of  the  Terms,  and  the  French 
and  other  Synonymes.  Edited  by  R.  J.  Dungli.on,  M.D.  In  one 
very  large  royal  8vo.  vol.  of  1139  pages.  Cloth,  $6  50;  leather, 
$7  50;  half  Russia,  $8. 

TIDES  (ROBERT  T)     TEXT-BOOK  OF  THERAPEUTICS  AND  MA- 

"*-*  TERIA  MEDIC  A.  In  one  8vo.  volume  of  544  pages.  Cloth,  $3  50  ; 
leather,  $4  50. 


F 


6  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

"pDIS  (ARTHUR  W.)  DISEASES  OF  WOMEN.  A  Manual  for  Stu- 
dents  and  Practitioners.  In  one  handsome  8vo.  vol.  of  676  pp., 
with  148  illustrations.     Cloth,  $3;  leather,  $4. 

pLLIS  (GEORGE  VINEE).  DEMONSTRATIONS  IN  ANATOMY. 
Being  a  Guide  to  the  Knowledge  of  the  Human  Body  by  Dissection. 
From  the  eighth  and  revii-ed  English  edition.  In  one  octavo  vol. 
of  71fi  pages,  with  249  illustrations.     Cloth.  $4  26  ;  leather,  $5  26. 

■pMMET  (THOMAS  ADDIS).     THE  PRINCIPLES  AND  PRACTICE 

-^     OF  GYNiECOLOGY.  for  the  use  of  Students  and  Practitioners. 
Third  edition,  enlarged  and  revised.     In  one  large  Svo.  volume  of  • 
880  I  ages,  with  150  original  illustrations      Cloth,  $5;   leather,  $6. 

pRICHSEN  (JOHNF.)  THE  SCIENCE  AND  ART  OF  SURGERY. 
A  new  American,  from  the  eighth  enlarged  and  revised  London 
edition.  In  two  large  octavo  volunres  containing  2316  pages,  with 
984ilius.     Cloth,  $9;  leather,  $11. 

pARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS. 
Fourth  American  from  Fourth  English  edition,  revised  by  Frank 
Woodbury,  M.D.  In  one  12mo.  volume  of  581  pages.  Cloth,  $2  50. 
INLAYSON  (JAMES).  CLINICAL  DIAGNOSIS.  A  Handbook  for 
Students  and  Practitioners  of  Medicine.  Second  edition.  In  one 
12mo.  volume  of  682  pages,  with  158  illustrations.     Cloth,  $2  50. 

pLINT    (AUSTIN).     A    TREATISE  ON   THE  PRINCIPLES    AND 

■*-  PRACTICE  OF  MEDICINE.  Sixth  edition,  thoroughly  revised 
and  largely  rewritten  by  the  Author,  assisted  by  William  H.  Welch, 
M.D  ,  and  Austin  Flint,  Jr.,  M.D.  In  one  large  Svo.  volume  of 
1160  pages,  with  illustrations.     Cloth,  $5  50  ;  leather,  $6  50. 

A  MANUAL   OF  AUSCULTATION  AND  PERCUSSION;    of 

the  Physical  Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of 
Thoracic  Aneurism.  Fifth  edition,  revised  by  James  C.  Wilson, 
M.D.  In  one  handsome  12mo.  volume  of  274  pages,  with  12  illus- 
trations.    Cloth,  $1  75. 

APRACTICALTREATISEONTHEDIAGNOSISANDTREAT- 

MENT  OF  DISEASES  OF  THE  HEART.  Second  edition,  enlarged 
In  one  octavo  volume  of  550  pages.     Cloth,  $4  00. 

A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EXPLORA- 
TION OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES 
AFFECTING  THE  RESPIRATORY  ORGANS.  Second  and  revised 
edition.     In  one  octavo  volume  of  591  pages.     Cloth,  $4  50. 

MEDICAL  ESSAYS.    In  one  12mo.  vol.,  pp.  210.    Cloth,  $138. 

ON    PHTHISIS:    ITS    MORBID    ANATOMY,    ETIOLOGY, 

ETC.  A  series  of  Clinical  Lectures.  In  one  8vo.  volume  of  442 
pages.     Cloth,  $3  50. 

pOLSOM  (0.  F.)     An  Abstract  of  Statutes  of  U.  S.  on  Custody  of  the 

^  Insane.  In  one  Svo.  vol.  of  108  pp.  Cloth,  $1  60,  Also  bound 
with  Clonstoii  ^ju  hisanity. 

pOSTER  (MICHAEL).  A  TEXT-BOOK  OF  PHYSIOLOGY.  Fourth 
and  revir^ed  American  from  the  fifth  English  edition.  In  one  large 
octavo  volume  of  1054  pages,  with  282  illustrations.  Cloth,  $4  50; 
leather,   $5  50. 


LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 


pOTHERGILL  (J.  MILNEB).  THE  PRACTITIONER'S  HANDBOOK 

OF  TREATMENT.     Third  edition.     In  one  handsome  octavo  vol- 
ume of  664  pnges.     Cloth,  $3  75  ;  leather,  $4  75. 

pOWNES  (GEORGE) .  A  MANUAL  OF  ELEMENTARY  CHEMISTRY 
(INORGANIC  AND  ORGANIC).  New  edition.  Embodying  Watts' 
Physical  and  Inorsanic  Chemistry.  In  one  royal  12mo.vol.  of 
1061  pages,  with  163  illus.,  and  one  colored  plate.  Cloth,  $2  75; 
leather,  $3  25. 

pox  (TILBURY)  and  T.  COLCDTT.  EPITOME  OF  SKIN  DIS- 
EASES, with  Formulae.  For  Students  and  Practitioners.  Third 
Am.  edition,  revised  by  T.  C.  Fox.  In  one  small  12mo.  volu;ne 
of  238  pages.     Cloth,  $1  25. 

pRa.NKLAND  (E.)  and  JAPP  (F.  R.)  INORGANIC  CHEMISTRY. 
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2  plates.     Cloth,  $3  75;  leather,  $4  75. 

pULLER  (HENRY).  ON  DISEASES  OF  THE  LUNGS  AND  AIR 
PASSAGES.  Their  Pathology,  Physical  Diagnosis,  Symptoms  and 
Treatment.   From2JEng.ed     In  1  Svo.  vol. ,  pp.  475.   Cloth,  $3  50. 

riANT  (FREDERICK  JAMES).  THE  STUDENTS  SURGERY.  A 
Multum  in  Parvo.  In  one  square  octavo  volume  of  845  pages,  with 
159  engravings.     Cloth,  $3  75. 

piBBES  (HENEAGE).  PRACTICAL  PATHOLOGY.  In  one  very 
handsome  octavo  volume  of  314  pages,  with  60  illustrations,  mostly 
photographic.     Cloth,  $2  75. 

piBNEY  (V.  P.)  ORTHOPEDIC  SURGERY.  For  the  use  of  Prac- 
titioners  and  Students.     In  one  8vo.  vol.  profusely  illus.     Prepg. 

pOULD    (A.   PEARCE).     SURGICAL    DIAGNOSIS.      In   one    12mo. 

^     vol.  of  589  pages.    Cloth,  .$2.    See  Students'  Series  of  Manuals,  p.  14. 

GRAY  (HENRY).  ANATOMY,  DESCRIPTIVE  AND  SURGICAL. 
Edited  by  T.  Pickering  Pick,  F.R  C.S.  A  new  American,  from  the 
eleventh  English  edition,  thoroughly  revised,  with  additions,  by 
W.  W,  Keen,  M  D.  To  which  is  added  Holden's  "Landmarks, 
Medical  and  Surgical."  In  one  imperial  octivo  volume  of  1098 
pages,  with  6S5  large  and  elaborate  engravings  on  wood.  Cloth,  $6  : 
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same  edition  is  also  i*sued  with  veins,  arteries,  and  nerves  distin- 
guished in  colors.  Price,  cloth,  $7  25;  leather,  $8  25;  half  Rus- 
sia, $8  75. 
GRAY  (LANDON  CARTER).  A  TREATISE  ON  NERVOUS  AND 
MENTAL  DISEASES,  for  Students  and  Practitioners  of  Medicine. 
In  one  handsome  octavo  volume  of  681  pages,  with  168  illustra- 
tions Cloth,  $4  50;  leather,  $3  50.  Just  ready. 
GREEN  (T.  HENRY).  AN  INTRODUCTION  TO  PATHOLOGY  AND 
MORBID  ANATOMY.  Sixth  American,  from  the  seventh  London 
edition.  In  one  handsome  octavo  volume  of  540  pages,  with  167 
illustrations.     Cloth,  $2  75. 

GREENE  (WILLIAM  H.)  A  MANUAL  OF  MEDICAL  CHEMISTRY. 
For  the  Use  of  Students.  Based  upon  Bowman's  Medical  Chem- 
istry. In  one  12mo.  vol.  of  310  pages,  with  74  illus.  Cloth,  $1  75. 
GRIFFITH  (ROBERT  E.)  A  UNIVERSAL  FORMULARY,  CON- 
TAINING THE  METHODS  OF  PRE  PARING  AND  ADMINISTER- 
ING OFFICINAL  ANDOTHER  MEDICIi'ES.  Thirdand  enlarged 
edition.  Edited  by  John  M.  Maisch,  Phar.D.  In  one  large  8vo. 
vol.  of  775  pages,  double  columns.     Cloth,  $4  50  ;  leather,  $5  50, 


G 


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ROSS(SAMUFLD.)  A  SYSTEM  OF  SURGERY,  PATHOLOGICAL. 
DIAGNOSTIC,  THERAPEUTIC  AND  OPERATIVE.  Sixth  edi- 
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ing 2382  pages,  with  1623  illustrations.  Strongly  bound  in  leather, 
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—  A  PRACTICAL  TREATISE  ON  THE  DISEASES,  INJU- 
ries  and  Malformations  of  the  Urinary  Bladder,  the  Prostate  Gland 
and  the  Urethra.  Third  edition,  thoroughly  revised  and  much 
condensed,  by  Samuel  W.  Gross,  M.D.  In  one  octavo  volume  of 
574  pages,  with  170  illus.     Cloth,  $4  50. 

—  A  PRACTICAL  TREATISE  ON  FOREIGN  BODIES  IN  THE 


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GROSS  (SAMUFL  W.)  A  PRACTICAL  TREATISE  ON  IMPO- 
TENCE,  STERILITY.  AND  ALLIED  DISORDERS  OF  THE 
MALE  SEXUAL  ORGANS.  Fourth  edition.  Edited  by  F.  R. 
Sturgis.  M.D.  In  one  handsome  octavo  volume  of  165  pages,  with 
18  illustrations.     Cloth,  $1.50. 

HABERSHON  (S.  0.)  ON  THE  DISEASES  OF  THE  ABDOMEN, 
AND  OTHER  PARTS  OF  THE  ALIMENTARY  CANAL.  Second 
American,  from  the  third  English  edition.  In  one  handsome  8vo. 
volume  of  554  pages,  with  illus.     Cloth,  $3  60. 

HAMILTON  (ALLAN  McLANE)      NERVOUS   DISEASES,   THEIR 
DESCRIPTION  AND  TREATMENT.    Second  andrevisededition 
In  one  octavo  volume  of  598  pages,  with  72  illustrations.    Cloth,  $4. 

HAMILTON  (FRANK  H.)  A  PRACTICAL  TREATISE  ON  FRAC- 
TURES AND  DISLOCATIONS.  New  Eighth  edition,  revised  and 
edited  by  Stephen  Smith,  A.M.,  M.D.  In  one  handsome  8vo.  vol. 
of  832  pages,  with  507  illustrations.   Cloth,  $5  50  ;  leather,  $6  50. 

HAEDAWAY  (W  A)  MANUAL  OF  SKIN  DISEASES.  In  one 
12mo.vol.of  440  pages.  Cloth,  $3. 
HARE  (HOBART  AMORY)  A  TEXT-BOOK  OF  PRACTICAL 
THERAPEUTICS,  with  Special  Reference  to  the  Application  of 
Remedial  Measures  to  Disease  and  their  Employment  upon  a 
Rational  Basis.  With  articles  on  various  subjects  by  well-known 
specialists.  New  (3d)  and  revised  edition.  In  one  handsome  octavo 
volume  of  689  pages.  Cloth,  $3  75;  leather,  $4.75.  Just  ready. 
TIAEE  (HOBART  AMORY).  Editor.  A  SYSTEM  OF  PRACTICAL 
•^  THERAPEUTICS.  By  American  and  Foreign  Authors.  In  a 
series  of  contributions  by  78  eminent  Physicians.  Three  large 
octavo  volumes  comprising  3544  pages,  with  434  illustrations. 
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sale  by  subscription  only.      Address  the  Publishers. 

HARTSHORNE  (HENRY).  ESSENTIALS  OF  THE  PRINCIPLES 
AND  PRACTICE  OF  MEDICINE.  Fifth  edition.  In  one  12mo. 
volume,  669  pages,  with  144  illustrations.  Cloth,  $2  75;  half 
bound,   $3. 

A  HANDBOOK  OF  ANATOMY  AND  PHYSIOLOGY.     In  one 

]2mo.  volume  of  310  pnges,  with  220  illustrations.     Cloth,  $1  76. 

A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.  Com- 
prising Manuals  of  Anatomy,  Physiology,  Chemistry,  Materia 
Medica,  Practice  of  Medicine,  Surgery  and  Obstetrics.  Second 
edition.  In  one  royal  12mo.  volume  of  1028  pages,  with  477  illus- 
trations.    Cloth,  $4'25;    leather,  $5  00. 

HEEMAN  (G.  ERNEST).  FIRST  LINES  IN  MIDWIFERY.  In 
one  12mo.vol.  of  198  pnges,  with  SO  illustrations.  Cloth,  $1  25. 
See  Students^  Series  of  Manuals,  p.  14. 

HERMANN  (L)  KXPERIxMENTAL  PHARMACOLOGY.  A  Hand- 
book of  the  Methods  for  Determining  the  Physiological  Actions  of 
Drugs.  Translated  by  Robert  Meade  Smith,  M.D.  In  one  12mo.  vol. 
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LEA  BROTHERS  &  CO.'S  PUBLICATIONS.  9 

HILL  (BERKELEY).  SYPHILIS  AND  LOCAL  CONTAGIOUS  DIS- 
ORDERS. In  one  Svo.volumeof  479  pages.  Cloth.  $3  25. 
HILLIER  (THOMAS).  A  HANDBOOK  OF  SKIN  DISEASES.  2d  ed. 
In  one  royal  12mo.  vol.  of  353  pp. ,  with  two  plates.  Cloth,  $2  25. 
HIRST  (BARTON  C.)  AND  PIERSOL  (GEORGE  A.)  HUMAN  MON- 
STROSITIES. Magnificent  folio,  containing  about  150  pages  of 
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Limited  edition,  for  sale  by  subscription  only. 

HOBLYN  (RICHARD  D.)  A  DICTIONARY  OF  THE  TERMS  USED 
IN  MEDICINE  AND  THE  COLLATERAL  SCIENCES.  In  one 
12mo.  vol.  of  520  double-columned  pp.    Cloth,  $150;  leather,  $2. 

HODGE  (HUGH  L.)  ON  DISEASES  PECULIAR  TO  WOMEN,  IN- 
CLUDING  DISPLACEMENTS  OF  THE  UTERUS.  Second  and 
revised  edition.     In  one  8vo.  volume  of  519  pages.     Cloth,  $4  50. 

HOFFMANN  (FREDERICK)  AND  POWER  (FREDERICK  B.)  A 
MANUAL  OF  CHEMICAL  ANALY^SIS,  as  Applied  to  the  Examina- 
tion of  Medicinal  Chemicals  and  their  Preparations.  Third  edition, 
entirely  rewritten  and  much  enlarged.  In  one  handsome  octavo 
volume  of  621  pages,  with  179  illustrations.     Cloth,  $4  25. 

H OLDEN  (LUTHER) .  LANDMARKS.  MEDICAL  AND  SURGICAL. 
From  the  third  English  edition.  With  additions,  by  W.  W.  Keen, 
M.D.     In  one  royal  12mo.  vol.  of  148  pp.     Cloth,  $1. 

HOLLAND  (SIR  HENRY).  MEDICAL  NOTES  AND  REFLECTIONS. 
From  3d  English  ed.  In  one  Svo.  vol.  of  493  pp.  Cloth,  $3  50. 
HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Principles 
and  Practice.  A  new  American  from  the  fifth  English  edition.  Edited 
by  T.  Pickering  Pick  F.R  C  :s  In  one  handsome  octavo  volume  of 
1008  pages,  with  428  engravings.     Cloth,  $6  ;  leather,  $7. 

A  SYSTEM  OF  SURGER'i:.   With  notes  and  additions  by  various 

American  authors.  Edited  by  John  H.  Packard,  M.D.  In  three  very 
handsome  Svo.  vols,  containing  3137  double  columned  pages,  with 
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HORNER  (WILLIAM  E.)  SPECIAL  ANATOMY  AND  HISTOLOGY. 
Eighth  edition,  revised  and  modified.  In  two  large  Svo.  vols,  of  1007 
pages,  containing  320  woodcuts.     Cloth,  $fi. 

HUDSON   (A.)      LECTURES   ON    THE    STUDY    OF   FEVER.      In 
one  octavo  volume  of  308  pages.     Cloth,  $2  50. 
HUTCHINSON  (JONATHAN).  "  SYPHILIS.    In  one  pocket  size  12mo. 
volume  of  542  pagis,   with  8  chromo-lithographic   plates.     Cloth, 
$2  25.      See  Series  of  Clinical  Mavnols,  p.  13 

HYDE  (JAMES  NEVINS) .  A  PRACTICAL  TREATISE  ON  DISEASES 
OF  THE  SKIN.     Second  edition.    In  one  handsome  octavo  volume 

of  676  pages,  with  85  engravings  and  2  colored  plates.   Cloth,  $4  50; 

leather    S5  50. 
TACKS0n'(GE0B:GE  T).    THE  READY-REFERENCE    HANDBOOK 
"      OF  DISEASES  OF  THE  SKIN.     In  one  12mo.  vol.  of  544  pp.,  with 

50  illustrations.     $2.75.     fast  ready. 
TAMIESON  (W.ALLAN).    DISEASES  OF  THE  SKIN.    Third  edition. 
"      In  one  octavo  volume  of  656  pages,  with  wood-cut  and  9  double-page 

chromo-lithographic  plates.     Cloth,  $6. 
TONES  (C.  HANDFlELD).    CLINICAL  OBSERVATIONS  ON  FUNC 
J       TIONAL  NERVOUS  DISORDERS.    Second  Americanedition.    In 

one  octavo  volume  of  340  pages.     Cloth.  S3  25. 
TULER  (HENRY)        A  HANDBOOK  OF   OPHTHALMIC    SCIENCE 
J      AND   PRACTICE.      In   one  Svo.   volume   of  442  pages,   with   124 

wood-cuts,  27  chromo-lithographic  plates,  test  types  of  Jaeger  and 

Snellen    and    Holmgren's    Color  blindness   test.      English   edition. 

Cloth,  $5  50;  leather,  $6  50. 

KING  (A.F.  A.)  A  MANUAL  OF  OBSTETRICS.  New  (5th)  ed.  In 
one  12mo.  vol.  of  446  pp.,  with  150  illus.  Clcth,  $2.50.  Just  ready. 


10  LEA  BROTHERS  &  CO.'S  PQBLICATrONS. 


^LEIN  (E )  ELEMENTS  OF  HISTOLOGY.  Fourth  edition.  In 
one  pocket-size  12mo.  volume  of  37G  pages,  with  194  engravings. 
Cloth,  $1  75.      See  Stiiflffits'  Series  of  Mannnls,  p.  14. 

JANDIS  (HENRY  G)  THE  MANAGEMENT  OF  LABOR.  In  one 
han  l?ome  12mo.  volume  of  329  pages,  with  28  illas.     Cloth,  $1   75. 

LA  ROCHE  (R  )    YELLOW  FEVER.    In  two  8vo.  vols,  of  1468  pages. 
Cloth,  $7. 


PXEUMOXIA.    In  one  8vo.  vol.  of  490  pages.     Cloth,  $.3. 

T  AURENCE  (J.  Z.)   AND  MOON  (ROBERT  C.)      A   HANDY-BOOK 
-L"     OF  OPHTHALMIC  SURGERY.     Second  edition,  revi.^ed  bv  Mr. 

Laurence.  In  one  &\-o.  vol  pp.  227,  with  66  illus.  Cloth,  $2  75. 
TAWSON  (GEORGE).  INJURIES  OF  THE  EYE,  ORBIT  AND  EYE- 
-'-'     LTDS.     From  the  last  English  edition.     In  one  hand.=ome  octavo 

volume  of  404  pages,  with  92    illustrations.     Cloth.  $3  50. 
TEA    (HENRY   C).     CHAPTERS   FROM   THE    RELIGIOUS    HIS- 
■LJ     TORY  OF  SPAIN:    CEXSOR-HIP  OF  THE  PRESS;    MYSTICS 

AND  ILLU.MINATI;  THE  ENDEMONI.\DAS  :  EL  SANTO  NINO 

DE  LA   GUARDIA;    BRIANDA    DE   BARDAXL     In  one  12mo. 

volume  of  522  pages.     Cloth,  $2.50. 

FORMULARY  OF   THE    PAPAL   PENITENTIARY      In  one 

8vo.  vol.  of  221  pages,  with  frontispiece.     Cloth,  $2  50.     Just  ready. 

SUPERSTITION  AND  FORCE:   ESSAYS  ON  THE  WAGER 

OF  LAW,  THE  WAGER  OF  BATTLE,  THE  ORDEAL  AND 
TORTURE.  New  (4th)  edition,  thoroughly  revised.  In  one  hand- 
some royal  12mo.  vol    of  629  pages.      Cloth.  $2  75.     Just  ready. 

STUDIES  IN  CHURCH  HISTORY.     The  Riseof  the  Temporal 

Power — Benefit  of  Clergy — Excommunication.  New  edition.  In 
one  handsome  12mo.  vol.  of  605  pp.     Cloth,  $2  50. 

AN   HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY 


IN  THE  CHRISTIAN  CHURCH.     Second  edition.     Inonehand- 

some  octavo  volume  of  685  p;.ges.      Cloth.  $4  50. 
TEDGER.    THE  MEDICAL  NEWS  PHYSICIANS  LEDGER.    Con- 
J-l     tains  300  pages  ledger  paper    ruled  in  approved    style.     Strongly 

bound  with  patent  flexible  bick.      Price,  $4 

LEE  (HENRY)  ON  SYPHILIS.  In  oneSvo  volume  of  246  pages. 
Cloth,  $2  25. 

TEHMANN  (C.  G.)     A  MANUAL   OF    CHEMICAL  PHYSIOLOGY, 
-LJ     In  one  8vo.  vol.  of  327  pages,  with  41  woodcuts.    Cloth,  $2  25. 
T  EISHMAN  (WILLIAM).     A  SYSTEM  OF  MIDWIFERY.     Includ- 
-'-•     ing  the  Diseases  of  Pregnancy  and  the   Puerperal  State.      Fourth 

edition.     In  one  octavo  volume  of  about  800    pages,   with  about 

225  illustrations. 

LUCAS  (CLEMENT).  DISEASES  OF  THE  URETHRA.  Preparing. 
See  Series  of  Cliyiical  Manuals,  p.  13. 
LUDLOW  (J.  L.)  A  MANUAL  OF  EXAMINATIONS  UPON  ANAT- 
OMY.  PHYSIOLOGY,  SURGERY,  PRACTICE  OF  MEDICINE, 
OBSTETRICS,  MATERIA  MEDICA,  CHEMISTRY,  PHARMACY 
AND  THERAPEUTICS.  To  which  is  added  a  Medical  Formulary. 
Third  edition.  In  one  royal  12mo.  volume  of  816  pages,  with  370 
woodcuts.  Cloth,  $3  25  ;  'leather,  $3  75. 
TUFF'S  MANUAL  OF  CHEMISTRY,  for  the  Use  of  Students  of 
1j  Medicine.  In  one  12mo.  volume  of  522  pages,  with  36  illustrations. 
Cloth,  '^2.     See  Students'  Series  of  Ma?i?'.als,  p.  14. 

LYMAN  (HENRY  M.).  THE  PRACTICE  OF  MEDICINE.  In  one 
very  handsome  octavo  volume  of  925  pages,  with  170  illu.^trations. 
Clolh,  S4  75  ;   leather,  $5  75. 

LYONS  (ROBERT  D.)  A  TREATISE  ON  FEVER.  In  one  octavo 
volume  of  302  pages.     Cloth,  $2  25. 


LEA   BROTHERS  &  CO.'S  PUBLICATIONS.  11 


M 
M 

M 


M 
M 

M 

M 

M 
M 


AISCH  (JOHN  M.)    A  MANUAL  OF  ORGANIC  xMATERIA  MED- 

ICA.       New  (5th)  edition.      In  one  very  handsome  12mo.  volume  of 

544  pages,  with  270  engravings.     Cloth,  $3. 
ARSH  (HOWARD).     DISEASES  OF  THE  JOINTS.     In  one  12mo. 

volume    of  468  pages,    with  64  illustrations  and    a  colored   plate. 

Cloth,  $2.      See  Series  of  Cli)iical  Manvah,  p.  13. 
AY  (C.  H.)    MANUAL  OF  THE  DISEASES  OF  WOMEN.    For  the 

use  of  Students  and  Practitioners.     Second  edition,  revised  bj  L. 

S.  Rau,  M.D.      In  one  12mo.  volume  of  360  pages,  with  31  illus- 

tratirns.     Cloth,  $1    75. 

EIGS  (CHAS.D.)  ON  THE  NATURE,  SIGNS  AND  TREATMENT 
OF  CHILDBED  FEVER.  In  one  8vo.  vol.  of  346  pages.  Cloth,  $2. 
ILLER  (JAMES) .  PRINCIPLES  OF  SURGERY.  Fourth  American, 

from  the  third  Edinburgh  edition.    In  one  large  octavo  voluma  of 

688  pages,  with  240  illustrations.     Cloth,  $3  75. 
ILLER    (JAMES).     THE    PRACTICE    OF    SURGERY.      Fourth 

American,  from  the  last  Edinburgh  edition.     In  one  large  octavo 

volume  of  682  pages,  with  364  illustrations.     Cloth,  83  75. 
ORRIS  (HENRY).     SURGICAL  DISEASES  OF  THE  KIDNEY. 

12mo.,  554  pages,  40  woodcuts,  and  6  colored  plates.     Cloth,  $2  25. 

See  Series  of  Clinical  Mcumals,  p.  13. 
ULLER  (J.)     PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY. 

In  one  large  8vo.  vol.  of  623  pages,  with  538  cuts.     Cloth,  $4  50, 
USSER  (JOHN  H.).     MEDICAL  DIAGNOSIS.     In  one  volume  of 

about  600  pages.     Preparing. 


'M'ATIONAL  DISPENSATORY.     See  Siille  ,V  Maisrh,  p.  14. 
"M-ATIONAL  MEDICAL  DICTIONARY.     See  Billings,  p.  3. 

NETTLESHIP  (E.)  DISEASES  OF  THE  EYE.  Fourth  American, 
from  fifth  Englii-h  edition.  In  one  royal  ]2ino.  volume  of  504 
pages,  with  164  illu.<!tr;itions,  test  types  and  formulae  and  color 
blindness  test.     Cloth,  $2. 

N ORRIS  (WM.  ^),  AND  OLIVER  (CHAS.  A.).  TEXT-BOOK  OF 
OPHTHALMOLOGY.  In  one  8vo.  volume  of  about  800  pages, 
with  illustrations.      In  press. 

OWEN  (EDMUND).  SURGICAL  DISEASES  OF  CHILDREN.  12mo., 
526  pages,  85  woodcuts,  and  4  colored  plates  Cloth,  $2.  See  Series 
of  Clinical  Manuals,  p.  13. 

PARRISH  (EDWARD).  A  TREATISE  ON  PHARMACY.  With  many 
Formulae  and  Prescriptions.  Fifth  edition,  enlarged  and  thoroughly 
revised  by  Thomas  S.  Wiegand,  Ph.G.  In  one  octavo  volume  of 
1093  pages,  with  257  illustrations.     Cloth,  $5  ;  leather,  $6. 

PARRY  (JOHN  S)  EXTRA-UTERINE  PREGNANCY.  ITS  CLIN- 
ICAL HISTORY,  DIAGNOSIS,  PROGNOSIS  AND  TREAT- 
MENT. In  one  octavo  volume  of  172  pages.  Cloth,  $2  50. 
PARVIN  (THEOPHILUS).  THE  SCIENCE  AND  ART  OF  OBSTET- 
RICS.  Second  edition.  In  one  handsome  8vo  volume  of  701 
pages,  with  239  engravings  and  a  colored  plate.  Cloth,  |4  25  ; 
leather,  $5  26. 

PAVY  (F.  W.)  A  TREATISE  ON  THE  FUNCTION  OF  DIGESTION, 
ITS  DISORDERS  AND  THEIR  TREATMENT.  From  the  second 
London  edition.     In  one  octavo  volume  of  238  pages.     Olf.th.  $2. 

PAYNE  (JOSEPH  FRANK).  A  MANUAL  OF  GENERAL  PATHOL- 
ogy.  Designed  as  an  Introduction  to  the  Practice  of  Medicine. 
Handsome  octavo  volume  of  524  pages  with  153  engravings  and  1 
colored  plate.     Cloth,  $3  50. 


12  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

pZPPER'S  SYSTEM  OF  MEDICINE.     See  p.  2. 

PEPPER  (A.  J  )     FORENSIC  MEDICINE.     Li  press.     See  Students' 
Series  of  Ma?/,iials,  p.  14. 


SURGICAL  PATHOLOGY.    In  one  12mo.  volume  of  511  pages, 

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Q 


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S' 


14  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

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16  LEA  BROTHERS  &  CO.'S  PUBLICATIONS. 

VAUGHAN  (VICTOR  C),  and  NOVY  (FBED'K  G.)  PTOMAINES 
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THE  STUDENT'S  BOOK  OF  CUTANEOUS  MEDICINE.     In 

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WINCKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED. 
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WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated 
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volume  of  550  pages.     Cloth,  $3  00. 

YEAR-BOOK.  OF  TREATMENT  FOR  1893.  A  Critical  Review  for 
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YEAR-BOOKb  OF  TREATMENT  FOR  1891  and  1892,  similar  to  above. 
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^^^"^-  ■^''■''- 


Date 

Due 

SEP  4 

19/4 

1       1Q7'1 

SEP 

\           1  J  i  T 

MSL 

LIBRARY 

PRINTED  IN  U.S.A.             CAT.    NO.    24    161                Bra 

Nettleship,  Edward 
Diseases  of  the  eye 


WWIOO 
NUT5d 
1890 


SSU  E  D  TO 


^/^;^ ) 


WWlOO 
1890 


Nettleship,  Edward 
Diseases  of  the  eye 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


